Safety concerns raised by coroners

Unsafe clinical responsibility for mental health leave and detention decisions 5 12 10 Mar 2026 Unsafe emergency egress arrangements 5 12 13 Jan 2025 Unsafe emergency response during lone working 5 11 14 Oct 2024 Unsafe management of ambulance calls involving callers who are alone 5 6 18 Feb 2025 Unsafe rapid tranquillisation processes 5 7 17 Jun 2026 Unsafe recognition and escalation of bowel obstruction 5 10 19 Sep 2025 Unsafe reliance on clinical questionnaires during patient assessment 5 14 18 Nov 2025 Unsafe staffing and cover arrangements for midwifery care 5 8 29 Sep 2022 Unsafe use and management of prone restraint 5 12 1 Aug 2025 Unsafe ventilator operation and safety controls 5 12 17 Jan 2023 Failure of emergency and search-and-rescue services to use mutually understood terminology 4 20 8 Jun 2023 Failure to communicate relevant risk information during patient leave 4 4 10 Mar 2026 Failure to ensure adequate supervision of emergency call handlers 4 4 15 Apr 2026 Failure to ensure clinical treatment approaches are supported by adequate evidence 4 10 17 May 2024 Failure to ensure complete clinical history and examination 4 14 18 Dec 2025 Failure to ensure diagnostic images are stored and available for safe clinical review 4 6 6 Jun 2025 Failure to ensure emergency services have reliable, timely access to shared accommodation 4 4 15 Mar 2023 Failure to ensure medication packaging is clearly distinguishable 4 14 2 Jun 2024 Failure to ensure naloxone is available and usable for opioid overdose emergencies 4 12 31 Mar 2025 Failure to ensure NHS 111 health advisors are competent for safe clinical triage 4 8 11 May 2026 Failure to ensure pregnant women have an individualised birth plan 4 5 30 Jun 2023 Failure to ensure staff competence to administer oxygen therapy 4 5 25 Nov 2020 Failure to escalate patient issues to multidisciplinary review 4 6 8 Feb 2022 Failure to escalate staffing shortages through the appropriate management pathway 4 4 3 Apr 2024 Failure to maintain accurate patient addresses and primary-care details 4 8 12 Jul 2024