Safety concerns raised by coroners

Unreliable out-of-area patient bed allocation and repatriation arrangements 3 5 19 Sep 2023 Unreliable pathology report tracking and follow-up 3 7 17 Oct 2023 Unreliable patient contact during urgent recall and follow-up 3 6 11 Jan 2023 Unreliable personal emergency alarms for people requiring assistance 3 4 6 Jun 2024 Unreliable police-hospital exchange of risk information during mental-health patient supervision 3 12 3 Jun 2024 Unreliable police safety response to suspected drug swallowing by detainees 3 7 4 Mar 2025 Unreliable pre-operative preparation and safety checks 3 6 17 Jan 2018 Unreliable prescription collection and delivery arrangements 3 7 8 Mar 2022 Unreliable prison fire detection systems 3 4 18 Mar 2026 Unreliable probation recall processes 3 6 26 Jul 2024 Unreliable procedures for recognising and confirming death 3 6 18 Jul 2018 Unreliable railway-station detection and alerting for persons on the line 3 5 29 May 2020 Unreliable rapid assessment and treatment for walk-in Emergency Department patients 3 8 11 Aug 2020 Unreliable recognition and assessment of anaemia 3 8 16 Sep 2021 Unreliable recording of police investigative actions and decisions 3 10 27 Nov 2023 Unreliable recording of reported crimes 3 3 30 Apr 2021 Unreliable recording of service-user movements 3 3 8 Jun 2023 Unreliable referrals to acute dietetic services 3 4 6 Nov 2018 Unreliable regulatory control of dangerous psychoactive substances 3 3 5 Nov 2024 Unreliable remote assessment and triage of ill infants 3 5 6 Jan 2026 Unreliable response to falls at elderly people's homes 3 4 12 Aug 2024 Unreliable road closure arrangements for hazardous roads 3 4 17 Jul 2024 Unreliable safeguarding information management in schools and colleges 3 3 4 Feb 2026 Unreliable safeguarding response to medication maladministration 3 3 12 Nov 2025 Unreliable safety arrangements for organised motorsport events 3 6 5 Feb 2025