Safety concerns raised by coroners
Explore concerns raised in Prevention of Future Deaths (PFD) reports.
Recurring concerns bring together individual concerns from different reports that describe the same underlying safety problem.
1,669 recurring concerns
Concern
Trend
Reports
Recipients
Latest report
Failure to ensure staff competence in fire safety and evacuation
6
19
19 Apr 2026
Failure to keep historical risk information accessible for later risk assessment
6
10
21 May 2024
Failure to maintain adequate visibility for patient monitoring
6
8
7 Jul 2023
Failure to provide emergency responders with readily accessible safety-critical patient information
6
13
23 Jan 2026
Failure to provide indicated antibiotic prophylaxis
6
10
22 Jan 2024
Failure to provide required mealtime supervision
6
12
19 Feb 2026
Failure to provide timely and competent mental health assessment after self-harm
6
15
26 Mar 2024
Failure to provide timely and reliable carer assessments
6
8
17 Apr 2025
Failure to provide timely clinical review during ambulance call handling
6
10
28 Oct 2025
Failure to recognise breathing emergencies during police encounters
6
12
7 Oct 2025
Failure to recognise physical illness in mental health patients
6
6
12 Aug 2024
Failure to reliably recognise and respond to drug and alcohol withdrawal in custody
6
15
20 Feb 2026
Failure to reliably verify medication information during care assessments
6
16
19 Mar 2026
Failure to review relevant care documentation before providing care
6
10
6 Jun 2024
Failure to secure suitable accommodation for people released from prison
6
10
27 Jan 2025
Failure to secure timely suitable alternative accommodation for vulnerable people
6
7
9 Mar 2026
Inadequate child safeguarding assessment
6
20
7 Feb 2025
Inadequate contingency planning for safe patient care during staffing shortages
6
10
4 Feb 2026
Inadequate fire detection and emergency notification for vulnerable people in housing
6
11
26 Apr 2022
Inadequate formal health and safety training for responsible staff
6
14
22 Feb 2024
Inadequate management of smoking-related fire risks in vulnerable people
6
10
3 Oct 2024
Inadequate pastoral support systems for identifying and responding to welfare concerns
6
9
10 Jul 2024
Inadequate professional registration and fitness-to-practise safeguards
6
13
28 Dec 2025
Inadequate recognition controls for atypical aortic emergencies
6
9
14 Oct 2025
Inadequate road-traffic-collision reporting for highway safety management
6
8
23 Jun 2025
Recurring concerns bring together reports that describe the same underlying safety problem. Open one to compare the individual concerns and original wording.
Data last updated 7 September 2026