Safety concerns raised by coroners

Failure to maintain adequate lighting in occupied premises 2 2 6 Sep 2023 Failure to maintain auditable records of safety-critical telephone communications and actions 2 3 27 Oct 2023 Failure to maintain complete and timely probation records 2 8 29 Aug 2019 Failure to maintain current tank-status information for live firing exercises 2 2 18 Jul 2018 Failure to maintain effective environmental cleaning in healthcare settings 2 3 15 Dec 2023 Failure to maintain effective regulatory airworthiness controls for aircraft 2 3 30 May 2025 Failure to maintain primary-care involvement in patients’ changing mental-health needs 2 7 14 Nov 2025 Failure to maintain safe indoor temperatures in occupied premises 2 3 5 Feb 2021 Failure to make required contact with approved family and support contacts 2 6 30 Jun 2023 Failure to make roadside obstructions visible to approaching road users 2 6 17 Sep 2019 Failure to manage sleep deprivation risks to mental health and suicide 2 5 27 Jun 2022 Failure to obtain and consider relevant treating psychiatrists' views 2 2 4 Feb 2026 Failure to obtain clinically indicated spinal imaging before treatment 2 2 26 Nov 2019 Failure to preserve and document fatal incident scenes for investigation 2 11 15 May 2022 Failure to prevent harmful isolation among vulnerable mental-health service users 2 5 13 Nov 2023 Failure to prevent unauthorised access to operational sites 2 3 25 Aug 2020 Failure to prevent undeclared allergens in food 2 10 21 Nov 2022 Failure to prevent unsafe access to elevated roofs 2 5 22 Oct 2025 Failure to prevent unsafe unaccompanied exit by vulnerable care-home residents 2 3 26 Oct 2022 Failure to prioritise clinical care over administrative work 2 3 2 May 2025 Failure to promptly enter and assess patients when welfare concerns arise 2 2 22 Aug 2022 Failure to protect safety-critical healthcare professional titles 2 2 26 Mar 2026 Failure to protect underage food-delivery riders from road traffic collisions 2 9 5 Dec 2025 Failure to provide accessible deportation information to detained prisoners 2 2 26 Jan 2022 Failure to provide adequate school swimming education 2 2 30 Jan 2025