Safety concerns raised by coroners

Unreliable patient risk-assessment processes 4 8 2 Jun 2021 Unreliable pharmacy clinical guidance and procedures 4 4 17 May 2024 Unreliable physiological observation and trend monitoring 4 8 3 Sep 2025 Unreliable placement and maintenance of police risk and vulnerability markers 4 7 27 May 2021 Unreliable police handling of reported sexual assault allegations 4 9 16 May 2023 Unreliable prevention and management of infective endocarditis 4 5 10 Mar 2026 Unreliable prison bullying management processes 4 7 28 Jan 2026 Unreliable PSIRF safety-incident decision and learning processes 4 4 14 Oct 2025 Unreliable public information about beach lifeguard coverage 4 3 7 Aug 2020 Unreliable railway rules for stopping trains to protect people in danger 4 4 13 Sep 2016 Unreliable receipt and routing of clinical correspondence by GP practices 4 10 23 Sep 2025 Unreliable recognition and communication of restraint-related acute behavioural disturbance risks 4 14 2 Feb 2026 Unreliable recording and availability of patient weight, height and BMI information 4 13 23 Jun 2025 Unreliable recording of care plan and risk assessment reviews 4 4 15 Jan 2024 Unreliable recording of safety-critical police contacts 4 16 26 Nov 2025 Unreliable recording of security-search outcomes 4 7 9 Sep 2024 Unreliable safeguarding response after suspected overdose 4 9 19 May 2021 Unreliable sharing of railway concern-for-welfare information with relevant responders 4 5 5 Aug 2025 Unreliable smoke-alarm interlinking and status information for vulnerable people 4 15 4 Oct 2022 Unreliable specialist perinatal mental-health service provision 4 6 13 Oct 2025 Unreliable telephone access to mental health services 4 6 20 Mar 2026 Unreliable terminology in obstetric delivery guidance and decisions 4 8 30 Apr 2026 Unreliable tracheostomy tube management and safety controls 4 9 8 Jan 2024 Unreliable treatment and observation of ingested foreign bodies 4 7 19 Jun 2024 Unreliable two-week-wait cancer referral pathways 4 6 13 Mar 2024