Safety concerns raised by coroners

Unreliable movement-alert systems for patients at high risk of falls 6 13 18 Dec 2024 Unreliable NHS-private mental-health discharge and referral arrangements 6 12 5 Sep 2025 Unreliable out-of-hours radiological reporting 6 9 31 Mar 2026 Unreliable oxygen administration and clinical oversight 6 10 18 Jul 2023 Unreliable police concern-for-welfare procedures 6 22 25 Apr 2024 Unreliable police-custody risk assessment processes 6 22 12 Aug 2024 Unreliable prevention and response to adrenal crisis 6 10 13 Aug 2024 Unreliable recognition and response to alcohol withdrawal 6 10 3 Sep 2025 Unreliable safe-release arrangements for high-risk offenders 6 10 13 Mar 2024 Unreliable safety assessment of new care-home residents on admission 6 13 11 Apr 2025 Unreliable safety controls for stationary vehicles on dynamic hard-shoulder motorways 6 1 17 Feb 2024 Unreliable Section 117 mental health aftercare arrangements 6 8 21 Nov 2025 Unreliable sedation guidance and practice 6 11 13 May 2024 Unreliable staff appraisal and performance-review processes 6 13 17 Sep 2025 Unreliable sudden-death response and investigation processes 6 16 25 Nov 2025 Unreliable supervision of members of the public on station premises 6 5 1 Jul 2025 Unreliable transfer of safety-critical patient information within ambulance services 6 12 5 Jan 2026 Unsafe access to and application of Naloxone guidance 6 17 10 Apr 2026 Unsafe disposal of medication 6 8 24 Jun 2026 Unsafe diving operations 6 9 30 Apr 2026 Unsafe management of required admissions when no bed is available 6 7 12 Feb 2026 Unsafe walking surfaces creating trip hazards 6 8 17 May 2021 Unsafe work-at-height operations 6 12 8 Mar 2021 Failure of external safety inspections to identify physical safety deficiencies 5 13 14 May 2024 Failure to assess room suitability and safety before placement 5 10 5 Feb 2024