Safety concerns raised by coroners

Failure to obtain clinically indicated repeat investigations 12 19 30 Jan 2026 Failure to provide clinically indicated psychiatric admission 12 22 24 Nov 2025 Failure to provide families with information needed to support people receiving mental health care 12 23 5 Jun 2025 Failure to provide patient-centred care and decisions 12 20 14 Jan 2026 Failure to reliably recognise and assess domestic abuse risks 12 24 19 Sep 2025 Failure to reliably record information and advice given to patients 12 13 2 Apr 2026 Inadequate controls for fatal falls from bridges 12 17 17 Feb 2025 Inadequate drainage control of hazardous surface water on public routes 12 11 21 May 2024 Inadequate management of malnutrition risk 12 21 27 Nov 2025 Inadequate mental health assessment before care decisions 12 29 1 Feb 2026 Inadequate physical nursing care for vulnerable patients 12 20 24 Apr 2026 Inadequate staff training for clinical and care record keeping 12 19 1 May 2025 Unreliable access to patients’ medication histories 12 19 3 Feb 2026 Unreliable and delayed surgical referral and review 12 22 29 Dec 2023 Unreliable communication in district nursing care coordination 12 21 21 May 2025 Unreliable communication of patients' nutritional requirements 12 14 22 May 2026 Unreliable decisions about when ambulance attendance is required 12 26 18 Mar 2026 Unreliable management of medication doses not taken 12 18 11 Mar 2025 Unreliable operational liaison between police and mental health services for safety-critical risk management 12 26 5 Mar 2026 Unreliable provision of safety-critical patient information to paramedics 12 15 28 Apr 2023 Unreliable recording and communication of patient allergy information 12 16 1 Aug 2025 Unreliable referral urgency categorisation and prioritisation 12 23 17 Apr 2025 Unreliable welfare-check request handling and follow-up 12 17 10 Jun 2026 Failure to accurately record the identities of clinicians involved in patient care 11 19 23 Jun 2025 Failure to ensure police officers receive and retain required training and operational guidance 11 13 25 Mar 2026