Safety concerns raised by coroners

Failure to reliably reposition patients at required intervals 14 17 26 Nov 2025 Inadequate 24-hour mental health crisis support 14 23 13 May 2026 Inadequate controls for drowning risks at open-water locations 14 24 26 Feb 2026 Inadequate medical assessment and escalation for unwell prisoners 14 25 24 Mar 2026 Inadequate provision of food for care residents 14 23 24 Feb 2026 Inadequate review of long-term medication use 14 28 30 Jun 2025 Inadequate safeguards against misuse of medicines with abuse potential 14 16 4 Dec 2025 Inadequate safeguards for access to dangerous drugs 14 19 29 Apr 2026 Incomplete medication safety guidance for prescribers 14 29 20 Nov 2023 Unreliable access to specialist mental health treatment for serious mental illness 14 27 6 Jul 2026 Unreliable circulation of safety-critical mental health information 14 29 8 Apr 2026 Unreliable diabetes care and management 14 20 12 Jun 2025 Unreliable dissemination of safety-critical clinical guidance and learning 14 17 4 Nov 2025 Unreliable emergency access arrangements for responders 14 22 20 Feb 2026 Unreliable fall-mat safety controls 14 23 3 Jun 2025 Unreliable operation of prison Code Blue emergency response 14 30 23 Mar 2026 Unreliable review and monitoring of repeat prescriptions 14 18 2 Feb 2026 Unreliable sharing of safety-critical risk information between police, healthcare and probation services 14 35 8 Apr 2026 Delays in progressing time-critical surgical treatment 13 14 5 Jun 2025 Failure to ensure care staff can communicate effectively with residents and patients 13 19 18 Jun 2025 Failure to ensure frontline personnel recognise mental-health indicators 13 30 8 Apr 2026 Failure to ensure patients receive the correct prescribed medication at hospital discharge 13 16 17 Oct 2023 Failure to maintain and share security and offender risk intelligence 13 32 22 Jan 2025 Failure to obtain timely specialist clinical advice when local expertise is insufficient 13 24 6 May 2026 Failure to provide effective consultant psychiatrist oversight in mental health care 13 24 4 Feb 2026