Safety concerns raised by coroners

Unreliable equipment for ambulance transfer of patients 3 3 19 May 2025 Unreliable firearms licensing decisions 3 9 16 Dec 2025 Unreliable fire-safety protection for telecare clients 3 9 21 Feb 2022 Unreliable forensic psychiatric assessment pathways for criminal-justice placement decisions 3 14 28 Jul 2017 Unreliable haematology clinical review and advice 3 7 28 May 2026 Unreliable hospital bleep systems for urgent clinical communication 3 3 1 Mar 2024 Unreliable hospital switchboard access and handling of urgent clinical requests 3 8 29 Dec 2023 Unreliable identification of urgent mental-health needs during initial screening 3 3 4 Oct 2024 Unreliable land-ownership determination for safety responsibilities 3 7 7 Aug 2024 Unreliable learning from white-goods fire information 3 16 6 Dec 2024 Unreliable Liaison and Diversion processes for people in custody 3 10 9 Aug 2024 Unreliable LOLER thorough examinations of lifting equipment 3 14 26 Sep 2022 Unreliable management of food and fluid refusal in prisons 3 10 10 Mar 2026 Unreliable management of prisoners’ outstanding hospital appointments 3 5 12 Oct 2023 Unreliable medication checking in care homes 3 3 14 Apr 2022 Unreliable medication supervision and escalation for mental health patients 3 3 8 Feb 2026 Unreliable Merlin safety-critical risk information 3 1 27 Nov 2020 Unreliable metabolic monitoring for patients taking antipsychotic medication 3 4 9 Jul 2015 Unreliable monitoring and moderation of harmful social-media content 3 13 8 Dec 2025 Unreliable national sharing of safety-critical incident information 3 10 18 Dec 2020 Unreliable neonatal infection guidance 3 7 12 Aug 2023 Unreliable nurse-to-doctor escalation in primary care 3 3 19 Oct 2023 Unreliable operation of Suicide Vulnerability Risk Assessment processes 3 3 29 Nov 2024 Unreliable operation of SystmOne for safety-critical prisoner information 3 6 19 Jan 2023 Unreliable operation of the STORM emergency incident-management system 3 4 28 Mar 2024