Safety concerns raised by coroners

Unreliable alcohol detoxification care and support 9 15 9 Dec 2020 Unreliable AWOL response processes 9 15 7 Apr 2025 Unreliable clinical task management and follow-through 9 16 25 Jun 2026 Unreliable communication within and between community mental-health teams 9 17 16 Jan 2026 Unreliable completion and tracking of requested clinical investigations 9 16 22 Aug 2025 Unreliable defibrillator operation during resuscitation 9 16 8 Feb 2026 Unreliable documentation and communication of shared clinical decisions 9 15 5 Feb 2026 Unreliable documentation of clinical triage decisions and advice 9 13 19 Mar 2025 Unreliable documentation of mental health assessments 9 17 27 May 2026 Unreliable emergency cell-entry arrangements in prisons 9 19 7 Apr 2026 Unreliable governance and accountability of multidisciplinary team decisions 9 14 22 Dec 2025 Unreliable GP appointment triage for determining clinical urgency 9 17 4 Apr 2025 Unreliable psychiatric appointment provision and coordination 9 11 18 Nov 2025 Unreliable recognition and management of pulmonary embolism 9 11 15 Sep 2025 Unreliable recording of patients' clinically relevant medical history 9 16 9 Jul 2025 Unreliable reporting of safety-relevant information to the CQC 9 21 10 Mar 2026 Unreliable RIO clinical-record functions 9 20 25 Nov 2024 Unreliable road-surface grip for vehicles 9 12 10 Jul 2025 Unreliable searches and screening for drugs and prohibited items in controlled environments 9 20 9 Sep 2024 Unreliable support for patients taking prescribed medication 9 19 2 Apr 2026 Unsafe clinical decisions by non-medically qualified personnel 9 17 2 Feb 2026 Unsafe continence care and management 9 21 22 Feb 2024 Unsafe management of central venous catheters 9 20 12 Dec 2024 Unsafe management of methadone treatment and intoxication risks 9 20 4 Mar 2024 Unsafe overtaking controls on hazardous road sections 9 14 2 Feb 2026