Safety concerns raised by coroners

Unreliable recording of required observations in care and custody 83 107 19 May 2026 Unsafe emergency call handling 79 104 16 Jun 2026 Delays in ambulance-to-hospital patient handover 77 53 18 Jun 2026 Unreliable assessment of suicide and self-harm risk 77 72 27 May 2026 Failure to escalate significant clinical concerns to appropriately senior clinicians 72 93 27 May 2026 Inadequate control of pedestrian crossing risks 71 66 8 Jun 2026 Failure to communicate safety-critical care information effectively between care providers and families 70 109 1 Jun 2026 Failure of care and safety auditing to identify deficiencies 69 101 16 Jun 2026 Electronic patient records failing to make relevant clinical information available and actionable 67 89 16 Jun 2026 Insufficient psychiatric inpatient bed capacity 67 49 12 Mar 2026 Unreliable clinical Early Warning Score systems for deterioration 67 72 5 Feb 2026 Unreliable clinical handover processes 67 95 10 Jun 2026 Failure to learn from deaths through systematic review 63 92 20 May 2026 Failure to identify and address recurring safety issues through organisational learning 62 110 20 May 2026 Failure to take timely escalation action when safety thresholds are breached 62 88 16 Mar 2026 Failure to provide effective senior clinical oversight of patient care 59 66 10 Mar 2026 Insufficient ambulance service capacity for emergency calls 58 45 2 Feb 2026 Insufficient medical staffing capacity for timely patient care 57 74 4 Feb 2026 Failure to seek medical attention when a person's condition warrants it 56 88 16 Jun 2026 Unreliable resuscitation preparedness and response during cardiac arrest 56 82 26 May 2026 Failure to provide timely and adequate follow-up after discharge 55 74 23 Oct 2025 Inadequate safety controls at high-risk road junctions 55 63 11 Dec 2025 Incomplete clinical history-taking 55 76 31 Oct 2025 Unsafe management of inpatient leave and absence 55 57 1 Jun 2026 Failure to identify clinically significant medication risks 54 83 3 Jun 2026