Safety concerns raised by coroners

Failure to reconcile conflicting information in safety assessments 5 17 26 Apr 2023 Failure to reliably audit emergency call handling 5 18 16 Jun 2026 Failure to reliably conduct and record skin inspections 5 7 11 Jun 2025 Failure to reliably diagnose and refer suspected DVT 5 10 15 Sep 2025 Failure to reliably identify and escalate self-neglect risks 5 11 24 Nov 2024 Failure to reliably learn from medication incidents and implement safeguards 5 10 19 Mar 2026 Failure to reliably monitor and interpret infant growth centiles 5 7 6 Jun 2025 Failure to reliably notify specialist teams of hospital admissions and discharges 5 9 19 Nov 2025 Failure to reliably preserve handover records 5 10 14 Sep 2023 Failure to reliably recognise and assess unconsciousness 5 11 7 Oct 2025 Failure to reliably send required mental health service communications to service users 5 7 10 Aug 2022 Failure to reliably share road-safety incident information with highway authorities 5 9 23 Jun 2025 Failure to safely coordinate transfer of urgent surgical patients 5 6 18 Feb 2025 Failure to verify patient suitability before online sale of restricted medicines 5 9 23 Apr 2025 Failure to verify staff receipt and understanding of safety policies 5 11 29 Jun 2026 Inadequate anaphylaxis safety education for patients, parents and schools 5 22 20 Aug 2024 Inadequate clarity of fire-safety standards and guidance 5 7 22 Oct 2025 Inadequate competence in neonatal resuscitation 5 10 10 Feb 2025 Inadequate controls for combined sedative medication toxicity 5 8 29 Dec 2025 Inadequate controls on access to prescription-only medicines outside regulated prescribing 5 4 23 Apr 2025 Inadequate emergency access during barricade incidents 5 8 22 Jan 2025 Inadequate fire risk assessments 5 10 19 Apr 2026 Inadequate front-obstruction visibility controls for large vehicles 5 6 2 Sep 2022 Inadequate handrail safety on steps and access ramps 5 7 27 Mar 2026 Inadequate management of foreign-body ingestion risks 5 9 14 May 2026