Safety concerns raised by coroners

Unreliable operation of the Manchester Triage System 5 7 8 May 2026 Unreliable out-of-hours interventional radiology support 5 9 28 May 2024 Unreliable paediatric early warning score (PEWS) systems 5 8 13 Mar 2025 Unreliable Personal Officer scheme for identifying and monitoring prisoner vulnerability 5 7 20 Apr 2020 Unreliable police handovers of safety-critical information 5 8 23 Jan 2026 Unreliable postoperative clinical review and complication response 5 9 13 Dec 2024 Unreliable post-operative PEG care and complication management 5 7 4 Aug 2023 Unreliable pre-activity safety information for organised water activities 5 7 10 Apr 2025 Unreliable prioritisation of patient reviews 5 5 17 Apr 2025 Unreliable prison cell safety inspection and risk-assessment processes 5 10 3 Mar 2026 Unreliable prison keyworker support scheme 5 8 6 Nov 2025 Unreliable prison staff communication during safety-critical situations 5 8 23 Mar 2026 Unreliable provision, reliability and use of pulse oximetry 5 12 30 Apr 2026 Unreliable recording and checking of placement risk information 5 11 10 Oct 2025 Unreliable recording of prisoner risk assessments and decisions 5 12 20 Apr 2020 Unreliable response to patient absconding 5 9 6 Feb 2026 Unreliable safety arrangements for midwifery-led home birth care 5 7 30 Apr 2026 Unreliable safety controls for cots and cot sides 5 11 26 May 2025 Unreliable Section 135 mental health warrant procedures 5 18 24 Apr 2026 Unreliable sharing of information about absent mental-health patients with police 5 14 6 Feb 2026 Unreliable specialist and forensic support for death investigations 5 13 11 Dec 2025 Unreliable transfer of diagnostic images between healthcare organisations 5 8 5 Mar 2024 Unreliable use of hospital passports to support safe care 5 7 7 Jul 2025 Unreliable X-ray request and progression processes 5 9 24 May 2022 Unsafe application of Mental Health Act detention safeguards to informal patients 5 7 6 Feb 2026