Safety concerns raised by coroners

Unreliable documentation of falls-risk management 16 22 25 Feb 2026 Unreliable emergency-department triage 16 22 10 Oct 2025 Unreliable medication dosage verification and communication 16 23 16 Mar 2026 Unreliable medication-specific blood-level monitoring 16 25 14 Jan 2026 Unreliable radiology processes for communicating findings and initiating required follow-up 16 20 4 Mar 2026 Unsafe controls for intoxication requiring medical attention 16 46 24 Mar 2026 Failure to maintain an open and accountable safety culture 15 30 1 Aug 2025 Failure to maintain clear ownership of multi-agency support and care 15 20 15 Jun 2026 Failure to provide adequate supervision of care staff 15 26 17 Oct 2024 Failure to provide effective on-duty clinical leadership 15 21 8 Feb 2024 Failure to provide fundamental personal care and welfare 15 25 22 Jul 2024 Failure to provide timely antibiotic treatment for suspected or confirmed infection 15 23 7 Feb 2026 Inadequate assessment of care needs before accepting patients into care 15 33 18 Jun 2025 Inadequate staff training for emergency response 15 32 18 Mar 2026 Incomplete and unreliable information about carers and care arrangements 15 26 5 Dec 2025 Unreliable communication and coordination across maternity care providers 15 21 5 Aug 2025 Unreliable completion of admission documentation 15 19 28 Aug 2025 Unreliable disclosure of relevant evidence in formal proceedings 15 23 15 Dec 2025 Unreliable DVLA medical fitness notification arrangements 15 13 27 Apr 2026 Unreliable integration of substance misuse services into patient care 15 24 3 Mar 2026 Unreliable social care referral pathways 15 26 30 Jan 2026 Failure to assess and meet patients’ mobility needs 14 18 11 Mar 2026 Failure to escalate patient-safety concerns to senior oversight 14 27 6 Feb 2026 Failure to reliably escalate requests for medical review 14 22 28 Mar 2025 Failure to reliably monitor patients' weights 14 30 23 Jun 2025