Safety concerns raised by coroners

Failure to reliably document the rationale for consequential decisions 54 84 27 May 2026 Failure to review relevant clinical records before care decisions 54 66 8 Jun 2026 Unreliable clinical safety-alert systems 53 70 1 Apr 2026 Failure to reliably recognise and respond promptly to sepsis 52 63 27 Feb 2026 Ineffective prison suicide and self-harm prevention systems 52 58 13 May 2026 Inadequate management of pressure ulcers 51 85 12 Mar 2026 Unreliable recording of safety-critical mental health information 51 66 27 May 2026 Unreliable ambulance call triage and re-triage 50 50 11 May 2026 Unreliable emergency access to hospital care 50 75 5 Jun 2026 Failure to reliably develop and review risk-reduction plans 48 61 2 Jun 2026 Unreliable escalation by care staff for required medical attention 48 72 30 Jan 2026 Failure to provide timely continuing mental health reviews and follow-up 47 74 25 Jun 2026 Failure to provide timely hospital admission 47 56 24 Nov 2025 Inadequate physical barriers preventing access to dangerous drops or areas 46 55 6 Mar 2026 Inadequate speed control at hazardous road locations 46 39 26 Mar 2026 Unreliable access to emergency communication 46 95 15 Apr 2025 Unreliable recording of fluid balance information 46 68 22 Dec 2025 Unreliable reporting of patient-safety incidents 46 65 1 Jun 2026 Failure to implement identified safety actions 45 54 24 Apr 2026 Unreliable handover of care information and responsibility 45 77 26 Jun 2026 Unreliable missing-person response 45 51 19 May 2026 Inadequate outdoor safety lighting 44 50 28 Nov 2025 Insufficient safe staffing and senior cover out of hours 44 53 26 May 2026 Unreliable post-fall assessment and clinical response 44 57 30 Mar 2026 Unreliable hospital discharge documentation 43 62 27 May 2026