Safety concerns raised by coroners

Inadequate psychiatrist review of mental health admission and discharge decisions 5 7 1 Aug 2025 Inadequate public water-rescue equipment and arrangements 5 7 26 Feb 2026 Inadequate safety warnings on medication packaging 5 16 15 Feb 2024 Inadequate signposting to mental health assistance and support 5 8 7 Apr 2026 Inadequate supervision of patients in acute hospital assessment areas 5 8 17 Dec 2025 Inadequate support for vulnerable patients during healthcare assessment and decisions 5 7 23 Aug 2021 Inadequate telephone mental health assessment 5 11 17 Oct 2024 Inadequate travel safety warnings about destination-specific hazards and standards 5 1 1 Nov 2023 Insufficient availability of certified safer cells for prisoners at risk of self-harm 5 7 10 Dec 2025 Insufficient availability of prison healthcare services outside limited operating hours 5 9 30 May 2025 Insufficient clinical staffing capacity for timely surgical care 5 6 5 Jun 2025 Insufficient controls on young and newly qualified drivers carrying young passengers 5 10 8 Dec 2025 Insufficient district nursing staffing capacity 5 5 27 Jun 2025 Insufficient emergency refuge provision on dynamic hard-shoulder motorways 5 2 18 Apr 2023 Insufficient maternity-service capacity and resilience for safe care 5 9 3 Jun 2025 Insufficient neurology service capacity for timely specialist assessment 5 5 11 Sep 2024 Insufficient psychological support for prisoners 5 8 6 Nov 2025 Insufficient regional capacity and mutual aid for time-critical specialist care 5 7 10 Sep 2025 Insufficient therapeutic pathways for people with personality disorders 5 9 28 Jul 2023 Insufficient width for safe cyclist passage 5 6 4 Nov 2024 Medication dispensing and dispatch errors not reliably detected 5 12 28 Nov 2024 Unclear inter-service roles and responsibilities for mental health assessment and liaison 5 13 30 Oct 2025 Uncontrolled public access to helium products 5 5 23 Oct 2023 Uncontrolled roadside obstacles endangering road users 5 8 11 Oct 2016 Unreliable access to clinically required cardiology tests 5 11 7 Apr 2025