Safety concerns raised by coroners

Incomplete, inaccurate or unavailable clinical and care records 474 425 26 Jun 2026 Unreliable hospital discharge processes 273 238 10 Jun 2026 Inadequate safety incident investigations 244 248 25 Jun 2026 Unreliable inter-agency information sharing for coordinated care 212 282 15 Jun 2026 Inadequate control of falls risks 165 185 21 May 2026 Failure to communicate clinically important information reliably between care services 144 186 10 Jun 2026 Unreliable patient observation arrangements 139 155 24 Jun 2026 Unreliable multi-agency communication procedures 134 236 16 Jun 2026 Unreliable communication of patient-care information between clinical staff 124 153 27 Feb 2026 Unreliable access to relevant clinical records for safe care 122 140 22 Jun 2026 Unsafe medication prescribing 121 177 25 Jun 2026 Unreliable care-planning processes 120 142 2 Jun 2026 Delays in ambulance attendance 118 66 23 Mar 2026 Inadequate mental health risk assessment 118 116 1 Jun 2026 Unsafe medication administration 115 146 19 Mar 2026 Unreliable mental health referral pathways 110 141 25 Jun 2026 Failure to ensure clinical investigation results are reliably available, interpreted and acted upon 108 121 25 Jun 2026 Failure to reliably recognise and respond to acute clinical deterioration 103 120 24 Jun 2026 Unreliable formal safety-incident management processes 103 119 10 Mar 2026 Unreliable healthcare patient transfer processes 103 129 24 Jun 2026 Inadequate staff competence to provide first aid 95 126 15 Jun 2026 Unreliable ACCT suicide and self-harm prevention processes 92 86 29 Jun 2026 Failure to provide continuity of patient care 88 121 15 Jun 2026 Insufficient qualified healthcare staffing capacity 85 96 1 Jun 2026 Inadequate road warning signage 84 74 1 Jun 2026