Safety concerns raised by coroners
Explore concerns raised in Prevention of Future Deaths (PFD) reports.
Recurring concerns bring together individual concerns from different reports that describe the same underlying safety problem.
1,669 recurring concerns
Concern
Trend
Reports
Recipients
Latest report
Unreliable medication management in care homes
11
16
30 Jan 2026
Unreliable recognition and response to illness in care-home residents
11
27
13 Jan 2026
Unreliable recording and confirmation of specialist clinical advice
11
19
21 Apr 2026
Unreliable recording of safeguarding information
11
38
25 Feb 2026
Unreliable recording of significant incidents and disclosures
11
26
8 Feb 2026
Unreliable referrals to district nursing services
11
20
21 May 2025
Unreliable referrals to tertiary specialist services
11
21
25 Jun 2026
Unreliable traceability of retrospective amendments to safety records
11
16
17 Mar 2026
Unsafe intravenous fluid management
11
23
7 Apr 2025
Unsafe provision of one-to-one care
11
16
24 Apr 2026
Excessive waiting times for specialist referrals
10
8
5 Jun 2026
Failure of Duty-of-Candour processes for significant incidents
10
19
15 Dec 2025
Failure of the highway hazard reporting and response process
10
17
6 Apr 2026
Failure to communicate clinically significant diagnostic findings to patients and care providers
10
11
20 Apr 2026
Failure to control vegetation that obstructs safety-critical visibility
10
17
9 May 2022
Failure to ensure mandatory safety training is completed before safety-critical work
10
22
17 Nov 2025
Failure to ensure safe sleeping arrangements for infants and children
10
9
26 Mar 2026
Failure to ensure staff competence in conducting and interpreting clinical observations
10
14
2 Jan 2025
Failure to escalate welfare concerns after unsuccessful contact
10
18
6 Mar 2026
Failure to maintain effective safeguarding review and monitoring
10
23
1 May 2026
Failure to preserve clinical evidence and data after serious clinical events
10
28
20 May 2026
Failure to prevent duplicate or discontinued medication prescriptions
10
19
14 Oct 2025
Failure to provide required reasonable adjustments for patients with disabilities
10
12
27 May 2026
Failure to provide safe pedestrian routes alongside roads
10
13
5 Dec 2024
Failure to recognise vulnerability in safeguarding decisions
10
23
30 May 2024
Recurring concerns bring together reports that describe the same underlying safety problem. Open one to compare the individual concerns and original wording.
Data last updated 7 September 2026