Safety concerns raised by coroners

Unreliable management of urinary catheters 8 8 2 Apr 2026 Unreliable Medical Priority Dispatch System emergency assessment and advice pathways 8 9 10 Oct 2025 Unreliable NOMIS safety-critical information access and visibility 8 13 8 Apr 2026 Unreliable observation of people in custody 8 18 7 Apr 2026 Unreliable physiotherapy provision for patients requiring care 8 13 29 Jul 2025 Unreliable police incident dispatch and response under service demand 8 9 8 May 2026 Unreliable recording and preservation of safety-relevant telephone calls 8 18 22 Jul 2024 Unreliable return-from-hospital arrangements 8 17 15 Apr 2025 Unreliable review of diagnostic imaging before consequential care decisions 8 11 25 Sep 2025 Unreliable risk assessment and management for patient transport 8 14 20 Aug 2025 Unreliable safeguarding review and learning processes 8 14 2 Oct 2025 Unreliable safety arrangements for lone workers 8 14 8 May 2024 Unreliable sharing of safety-critical information between police forces 8 14 20 Oct 2025 Unreliable specialist mental health support in hospital care 8 12 14 May 2026 Unreliable transfer and consideration of medical information during custody transitions 8 19 22 Mar 2024 Unsafe assurance of doctors' procedural competence 8 17 29 Aug 2025 Unsafe cell-sharing decisions for prisoners 8 10 15 Dec 2025 Unsafe emergency department care environments for people in mental health crisis 8 12 28 Oct 2025 Unsafe management of significant bleeding 8 15 13 Dec 2024 Unsafe pressure on hospital admission and discharge decisions from bed capacity constraints 8 13 17 Apr 2024 Unsafe remote clinical consultations for assessment and advice 8 13 6 Aug 2025 Excessive emergency-department waiting times 7 6 27 May 2025 Failure of organisational governance to act on escalated patient-safety concerns 7 9 8 Feb 2026 Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment 7 14 18 Aug 2025 Failure to actively engage mental health service users before discharge 7 11 23 Jun 2025