Repeated warnings
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32 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Sustained high operational pressure at REAP Level 4
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - 4 reports · 1 coronerClosely relatedConfidence 0.90 · high
- Ketamine misclassification as Class B drug
Home Office · National body
2 reports · 2 coronersIdentical hazardConfidence 0.96 · high - Inconsistent access to thrombectomy services
NHS England · National body
7 reports · 6 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - 4 reports · 4 coronersClosely relatedConfidence 0.90 · high
- Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Insufficient safeguards in long term opioid prescribing
Greater Manchester Integrated Care Board · Commissioner
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · high
- 2 reports · 2 coronersClosely relatedConfidence 0.85 · high
- Patient record system fails to display critical clinical information
County Durham and Darlington NHS Foundation Trust · NHS body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report
- Delayed ambulance response due to missed urgency recognition
North East Ambulance Service NHS Foundation Trust · Ambulance service
3 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inaccessible patient information across county boundaries
Surrey and Borders Partnership NHS Foundation Trust · NHS body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report - Lack of communication between hospital and care home regarding mental capacity
Surrey County Council · Local authority
2 reports · 2 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coronerClosely relatedConfidence 0.90 · high - Untrained police control room staff lack recognition of acute behaviour
College of Policing · National body
2 reports · 2 coronersIdentical hazardConfidence 0.90 · high - Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report