Safety concerns raised by coroners

Unreliable police emergency-vehicle siren controls 2 2 4 Jun 2021 Unreliable police search coordination and information 2 3 8 Nov 2016 Unreliable post-operative extubation decision and management 2 4 30 Sep 2019 Unreliable pre-activity safety liaison arrangements 2 3 1 Oct 2015 Unreliable prison response to positive drug tests 2 7 28 May 2025 Unreliable prison-to-court transfer information 2 4 26 Nov 2019 Unreliable progression of people through police custody 2 3 23 Jul 2019 Unreliable Prove The Gun drill procedures 2 2 18 Jul 2018 Unreliable provision and readiness of torches for safety-critical site and search work 2 2 30 Mar 2026 Unreliable public-protection safeguards for s41 restriction-order patients 2 6 16 Feb 2024 Unreliable public understanding of smart motorway safety arrangements 2 2 16 Sep 2022 Unreliable receipt, prioritisation and clinical review of hospital discharge summaries 2 2 3 Mar 2016 Unreliable recognition and management of nicotine withdrawal 2 4 15 Dec 2016 Unreliable recognition and referral of cancer red flags 2 3 5 Jun 2026 Unreliable recognition and response to heat illness in safety-critical operations 2 3 1 Nov 2019 Unreliable recognition and treatment of opioid withdrawal 2 7 10 Jan 2019 Unreliable recognition, monitoring and management of electrolyte abnormalities 2 7 14 Nov 2024 Unreliable recording and follow-up of clinical escalations 2 3 20 Jan 2026 Unreliable recording and involvement of prisoners’ next of kin 2 10 10 Mar 2026 Unreliable recording of clinical governance meeting concerns and actions 2 2 23 Apr 2025 Unreliable recording of designated doctor visits and review requests 2 3 7 Mar 2022 Unreliable recording of drug-related deaths and casualties 2 9 8 Dec 2025 Unreliable recording of safety-critical police incident locations 2 3 30 Mar 2026 Unreliable recording of safety-critical prisoner behaviour and welfare information 2 4 6 Oct 2017 Unreliable regulation and enforcement of e-scooter use 2 14 11 Jul 2023