Safety concerns raised by coroners

Failure to assess underlying process risks independently of existing controls 5 6 29 Sep 2023 Failure to control confirmation bias in safety-critical decision-making 5 14 14 Oct 2025 Failure to enable professional challenge of clinical decisions 5 8 27 Feb 2026 Failure to ensure safe accommodation after discharge from mental health care 5 6 9 Mar 2026 Failure to ensure safe appointment and oversight of locum doctors 5 12 9 Mar 2020 Failure to ensure safety-critical medical equipment is reliably visually identifiable 5 6 7 Jul 2021 Failure to ensure timely ambulance access to care and emergency treatment premises 5 13 25 Nov 2024 Failure to include material information in formal statements 5 6 14 Nov 2022 Failure to investigate prolonged unexplained symptoms 5 12 19 Jun 2024 Failure to maintain accurate next-of-kin information in healthcare records 5 7 6 Mar 2026 Failure to maintain healthcare continuity for prisoners after release 5 9 6 Feb 2026 Failure to maintain safety risks in corporate risk governance 5 8 13 Jan 2026 Failure to make relevant mental health assessment information available across care settings 5 9 8 Jul 2025 Failure to provide care for vulnerable people excluded by service thresholds 5 9 16 Dec 2024 Failure to provide clinically indicated ECGs 5 6 9 May 2025 Failure to provide essential domiciliary care 5 13 22 Jul 2024 Failure to provide prisoners with a safe and sufficiently accessible prison regime 5 12 24 Mar 2026 Failure to provide reliable community mental health assessments 5 12 18 Nov 2025 Failure to provide suitable accommodation for patients awaiting care 5 8 19 Jan 2026 Failure to provide timely direction and escort for arriving paramedics 5 8 25 Nov 2024 Failure to provide timely specialist review in emergency departments 5 7 28 Jun 2023 Failure to provide timely speech and language therapy for swallowing risks 5 10 1 Jul 2026 Failure to recognise and respond promptly to suspected meningitis 5 14 3 Jul 2019 Failure to recognise and respond to anaphylaxis 5 23 25 Nov 2025 Failure to recognise learning disabilities and associated support needs in healthcare 5 7 28 May 2026