Repeated warnings
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342 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of mental capacity assessment and risk assessment in emergency settings
Care Quality Commission · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Insufficient ambulance availability leading to delayed response
Department of Health and Social Care · National body
7 reports · 7 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 7 reports · 7 coronersClosely relatedConfidence 0.80 · moderateReviewed dossier
- Patients not informed of surgical risks in Turkey
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Insufficient complex neonatal resuscitation training
Royal College of Paediatrics and Child Health · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - Recurring hazard (see the quoted concerns)
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 3 reports · 3 coronersClosely relatedConfidence 0.85 · high
- Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Delayed community offender manager engagement before release
His Majesty's Prison and Probation Service · National body
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of clear information sharing protocols between probation and other agencies
Ministry of Justice · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 1 coronerClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate communication of SSRI suicide risk
Medicines and Healthcare products Regulatory Agency · National body
2 reports · 2 coronersIdentical hazardConfidence 0.85 · high - Lack of naloxone availability and training in prisons
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report