Safety concerns raised by coroners

Failure to control infection risks during care 7 9 28 Dec 2025 Failure to ensure adequate senior nursing leadership for safe patient care 7 11 4 Apr 2024 Failure to ensure employees have suitable personal protective equipment for workplace hazards 7 15 12 Feb 2025 Failure to ensure identified safety remedial works are completed 7 13 6 Nov 2024 Failure to ensure reliable renal monitoring for patients with renal disease 7 16 30 Jan 2026 Failure to establish patients’ consent for family involvement in mental health care 7 12 13 Nov 2023 Failure to identify and refer patients needing specialist respiratory input 7 13 30 Jan 2023 Failure to individualise medication doses to patient-specific factors 7 9 21 May 2024 Failure to initiate 999 calls promptly when life is at risk 7 11 26 May 2026 Failure to maintain contact with vulnerable people after initial engagement 7 12 10 Jul 2024 Failure to maintain safe care and support during service transitions 7 10 23 Jun 2025 Failure to provide coordinated skin care across healthcare services 7 19 11 Jun 2025 Failure to provide fetal monitoring when clinically required 7 13 8 Apr 2021 Failure to provide safe ongoing care during prolonged emergency-department stays 7 8 27 Jun 2025 Failure to provide timely access to urgent and out-of-hours endoscopy 7 8 13 Jan 2026 Failure to provide treating clinicians with relevant patient history and baseline information 7 11 30 Jul 2025 Failure to reassess treatment options when clinically indicated 7 10 25 Jun 2026 Failure to recognise agonal breathing 7 23 16 Apr 2026 Failure to recognise and respond to coercive and controlling behaviour 7 16 1 May 2026 Failure to reliably assure compliance with care plans 7 8 30 Aug 2024 Failure to reliably notify responsible consultants about admissions and significant clinical changes 7 15 3 Dec 2024 Failure to reliably record safety information received from external organisations 7 10 6 Feb 2026 Failure to reliably report self-harm and suicide risks to people able to help 7 9 18 Jun 2024 Failure to verify compliance and effectiveness of implemented safety changes 7 14 4 Jun 2025 Inadequate competence assurance and supervision for inexperienced midwives 7 11 2 Dec 2024