Safety concerns raised by coroners

Unreliable access to gender-affirming healthcare 5 9 25 Jul 2024 Unreliable adult safeguarding threshold assessment and response 5 6 3 Apr 2025 Unreliable allocation and referral of welfare support between police and ambulance services 5 12 25 May 2025 Unreliable ambulance emergency escalation and contingency arrangements 5 15 6 Jan 2026 Unreliable capture and reporting of anaphylaxis incidents 5 15 6 Apr 2023 Unreliable CCTV detection and tracking of people at risk 5 9 6 Sep 2021 Unreliable chest X-ray imaging and interpretation 5 11 4 Mar 2026 Unreliable clinical assessment and management of eating disorders 5 18 14 Feb 2024 Unreliable communication of detainee safety-critical risk information 5 15 27 Mar 2024 Unreliable communication of significant academic decisions and support actions to students 5 8 19 Jan 2024 Unreliable community care-coordinator provision and contact 5 10 25 Sep 2023 Unreliable community mental-health response to urgent GP concerns 5 10 14 May 2024 Unreliable confidentiality arrangements for sharing safety-critical welfare information 5 9 15 Jan 2020 Unreliable dissemination of safety alerts to relevant recipients 5 12 17 Feb 2021 Unreliable emergency-department streaming and initial assessment 5 10 28 Oct 2024 Unreliable falls risk assessment tools 5 5 19 May 2023 Unreliable guidance for decisions to stop or withhold resuscitation 5 9 19 Sep 2023 Unreliable highway-defect investigation and prioritisation 5 6 27 Feb 2026 Unreliable hospital destination selection for patient transfers 5 12 7 Dec 2023 Unreliable hospital pre-alert systems 5 10 19 May 2025 Unreliable hospital system access for temporary clinical staff 5 6 5 Dec 2025 Unreliable interpreter provision for healthcare communication 5 11 10 Dec 2025 Unreliable major haemorrhage response arrangements 5 8 13 Dec 2024 Unreliable monitoring of oxygen saturation during clinical care 5 9 21 Feb 2020 Unreliable operation of inter-provider healthcare service agreements 5 13 22 Nov 2022