Safety concerns raised by coroners

Failure to reliably investigate suspected bowel perforation 3 3 9 Feb 2026 Failure to reliably locate people at immediate risk of suicide or self-harm 3 6 8 Aug 2025 Failure to reliably make protective-order conditions available to responsible staff 3 8 26 Jul 2024 Failure to reliably monitor participants during organised sporting activities 3 5 14 Mar 2025 Failure to reliably notify receiving hospital staff of ambulance arrivals 3 6 1 Sep 2023 Failure to reliably provide recommended vaccinations to eligible people 3 3 10 Jun 2021 Failure to reliably recognise and control immersion pulmonary oedema risks in diving 3 9 30 Apr 2026 Failure to reliably recognise and manage delirium 3 5 7 Nov 2025 Failure to reliably recognise and treat hypovolaemia 3 4 13 Dec 2024 Failure to reliably recognise and treat raised intracranial pressure promptly 3 5 7 Jan 2021 Failure to reliably recognise respiratory distress in children 3 6 21 Feb 2020 Failure to reliably reconcile prescribed and dispensed medication 3 7 27 Nov 2023 Failure to reliably transfer complete information to transplant centres 3 5 14 Aug 2019 Failure to safely supervise patients receiving oxygen therapy 3 4 25 May 2022 Inaccurate calculation of prisoners’ release and sentence dates 3 2 2 Jun 2021 Inadequate audible movement-warning systems on vehicles and mobile equipment 3 3 27 Aug 2024 Inadequate CAA regulatory oversight of aviation safety 3 22 2 Aug 2024 Inadequate clinical competence to recognise and treat paediatric sepsis 3 10 28 Feb 2020 Inadequate clinical expertise for safe emergency patient assessment 3 6 4 Oct 2021 Inadequate clinical guidance for fracture management 3 5 21 Oct 2024 Inadequate clinician training for safe opioid prescribing and dosing 3 3 28 Sep 2020 Inadequate competence of personnel conducting safety audits and reviews 3 6 19 Jul 2022 Inadequate control of damp and mould hazards in residential properties 3 4 1 Dec 2025 Inadequate controls for air embolism during invasive procedures 3 8 1 Aug 2024 Inadequate controls for fire risks in domestic fridge-freezers 3 15 28 Jan 2019