Safety concerns raised by coroners

Unreliable cross-referencing of related patient records 4 11 9 Dec 2025 Unreliable documentation and communication of patients’ oxygen requirements 4 5 19 Mar 2025 Unreliable domestic abuse investigations 4 15 19 Sep 2025 Unreliable ECG use and interpretation for clinical decisions 4 6 5 Jun 2026 Unreliable emergency arrangements for organised public events 4 7 10 Apr 2025 Unreliable escalation of assessed safety risk levels 4 8 26 Jul 2024 Unreliable funding responsibility and referral arrangements for required care 4 8 28 May 2026 Unreliable handling of family and friend safety concerns about prisoners 4 11 22 Dec 2021 Unreliable healthcare referral for medically vulnerable detainees 4 6 4 Mar 2025 Unreliable hospital acceptance arrangements for patients requiring treatment 4 10 16 Apr 2025 Unreliable identification and support for gambling-related harm 4 6 14 Jan 2026 Unreliable intentional-rounding systems 4 7 5 Feb 2026 Unreliable interpretation and use of evidence in regulatory inspections 4 7 16 Apr 2024 Unreliable management and control of emergency incident scenes 4 7 24 May 2016 Unreliable management of patients returning to emergency departments soon after discharge 4 12 28 Jun 2023 Unreliable medical assessments in police custody 4 16 20 Feb 2026 Unreliable medical fitness controls for divers 4 8 18 Nov 2025 Unreliable Mental Health Act assessment documentation 4 5 27 May 2026 Unreliable Mental Health Act nearest-relative decision safeguards 4 4 29 May 2025 Unreliable monitoring and management of high-risk offenders in the community 4 14 1 Aug 2024 Unreliable named-nurse allocation and identification 4 6 29 Feb 2024 Unreliable neurological referral pathways 4 8 10 Feb 2020 Unreliable operation of the Lorenzo clinical information system 4 7 31 May 2024 Unreliable packaging and identification of dispensed medication 4 13 2 Jun 2024 Unreliable paediatric abdominal-pain assessment and escalation pathways 4 9 30 Mar 2026