Safety concerns raised by coroners

Failure to maintain uninterrupted access to clinically necessary medication 4 8 19 Mar 2026 Failure to move people in mental health crisis promptly from A&E to appropriate mental-health care 4 3 28 Oct 2025 Failure to provide accessible care for people with complex neurodevelopmental needs 4 6 15 Jan 2025 Failure to provide adequate supervision and emergency assistance coverage at recreational activity venues 4 6 5 Feb 2025 Failure to provide autism-informed care and communication for children 4 11 30 Mar 2026 Failure to provide clinicians with complete prisoner information for safe assessment 4 9 20 Dec 2024 Failure to provide required blood products promptly for transfusion 4 4 14 May 2024 Failure to provide safe accommodation for inpatient mental health patients 4 4 1 Feb 2023 Failure to provide safety warnings at point of sale for hazardous products and equipment 4 15 11 Apr 2025 Failure to provide smoke alarms in occupied accommodation 4 6 19 Feb 2026 Failure to provide sufficient clinical information for diagnostic imaging interpretation 4 6 26 Aug 2025 Failure to provide timely adult ADHD assessment and treatment 4 4 5 Feb 2026 Failure to provide trauma-informed hospital care 4 7 27 May 2026 Failure to recognise and provide joined-up care for menopause-related deterioration 4 8 24 Apr 2025 Failure to reliably detect and manage prolonged QTc syndrome 4 7 25 Nov 2025 Failure to reliably follow up accident reports to prevent recurrence 4 5 17 Jun 2025 Failure to reliably hand over fall information 4 4 17 Feb 2025 Failure to reliably identify and support students with emerging mental-health needs 4 10 10 Jul 2024 Failure to reliably implement consultant clinical instructions 4 5 12 Nov 2020 Failure to reliably implement multidisciplinary team recommendations 4 5 10 Feb 2023 Failure to reliably recognise acute abdominal emergencies 4 8 8 Nov 2024 Failure to reliably recognise when obstetric input is needed and obtain it promptly 4 9 13 Dec 2024 Failure to reliably respond to patient and carer communications 4 8 30 Jun 2025 Failure to reliably translate safety recommendations into actionable changes 4 8 19 May 2023 Failure to use the appropriate emergency contact route 4 11 6 Feb 2026