Safety concerns raised by coroners

Failure to ensure academic staff are competent to recognise and respond to student mental-health risks 3 7 19 Jan 2024 Failure to ensure access to required dialysis treatment 3 4 16 Jun 2017 Failure to ensure accountable and proactive repair of accommodation hazards for vulnerable residents 3 9 27 Mar 2019 Failure to ensure appropriate risk assessment during welfare visits 3 5 23 Nov 2023 Failure to ensure clinical governance staff are competent for safety oversight 3 6 29 Sep 2025 Failure to ensure experienced mental health professional involvement in care decisions 3 6 7 Aug 2022 Failure to ensure lift engineers are competent to install and service lifts 3 14 11 Jan 2023 Failure to ensure schools receive relevant child safeguarding information 3 10 14 Oct 2024 Failure to ensure timely specialist dermatology input for acute severe skin conditions 3 5 13 Oct 2023 Failure to escalate deteriorating patients for ICU involvement 3 4 17 Jul 2023 Failure to establish complete and reliable evidence for safeguarding allegations 3 7 31 Aug 2022 Failure to identify and respond to disclosed knife and offensive-weapon possession 3 5 1 May 2022 Failure to individualise bail conditions for vulnerable defendants 3 5 8 Jan 2025 Failure to integrate mental health and education pastoral services 3 6 1 Aug 2019 Failure to keep pedestrians out of cycle paths through clear safety guidance 3 5 1 Dec 2020 Failure to locate patients requiring assessment 3 8 8 Aug 2021 Failure to maintain driver visibility around parked vehicles 3 4 28 Nov 2025 Failure to make and document informed prosecution decisions in vulnerable cases 3 11 31 Aug 2022 Failure to make capacity-based decisions using relevant information and wishes 3 4 17 Apr 2024 Failure to make significant medical events accessible to relevant non-clinical staff 3 6 20 Feb 2015 Failure to obtain clinically indicated microbiological samples 3 5 1 Sep 2016 Failure to obtain critical information during initial police incident responses 3 6 19 Jul 2019 Failure to prevent vulnerable people from ingesting hazardous cleaning products 3 7 18 Jul 2025 Failure to promptly escalate patient falls to responsible senior clinicians and managers 3 4 10 Feb 2021 Failure to provide clear public information about accessing 999 and 111 emergency healthcare services 3 4 20 Sep 2024