Safety concerns raised by coroners

Unreliable recording of suicide-risk information 19 26 12 Jan 2026 Unreliable sharing of safety-critical risk information within prisons 19 28 8 Apr 2026 Failure to assure the quality of clinical and care records 18 30 16 Jun 2026 Failure to convene coordinated professional case-planning discussions for safety concerns 18 35 27 May 2026 Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending 18 34 19 Jan 2026 Failure to reliably telephone patients when follow-up or assessment requires it 18 27 12 Aug 2024 Insufficient detail in referrals for safe risk assessment and prioritisation 18 32 30 Mar 2026 Insufficient emergency-department staffing capacity for safe patient care 18 22 17 Dec 2025 Unreliable best-interests decision-making processes 18 31 23 Sep 2025 Unreliable coordination and information sharing between primary and secondary care 18 33 23 Sep 2025 Unreliable medication reconciliation across care transitions 18 34 19 Mar 2026 Unreliable morbidity and mortality review processes 18 27 14 Oct 2025 Unreliable observation of patients in specialist mental health units 18 22 1 Apr 2026 Unreliable review and action on clinically significant incoming correspondence 18 34 3 Jun 2026 Untimely or incomplete community care assessments 18 29 18 Nov 2025 Failure to consider or reconsider serious alternative diagnoses 17 40 9 May 2025 Failure to ensure discharge information is accessible and understood by patients and carers 17 23 3 Jun 2026 Failure to ensure safe discharge planning for inpatient mental health admissions 17 26 27 May 2026 Failure to incorporate relevant collateral and professional views into clinical assessment 17 32 6 Feb 2026 Failure to provide sufficient GP involvement in patient care 17 38 26 Mar 2026 Failure to provide timely clinical care 17 29 14 Jan 2026 Failure to reliably assess and diagnose injuries 17 23 9 Feb 2026 Failure to reliably follow up identified mental-health safety concerns 17 36 25 Jun 2026 Inadequate district nursing wound care 17 29 20 Aug 2025 Inadequate frontline training to recognise and respond to suicide and self-harm risk 17 25 7 Apr 2026