Safety concerns raised by coroners

Unreliable mental-health inpatient bed allocation decisions 2 3 14 Sep 2025 Unreliable mental health support pathways for young people who disengage 2 6 9 Mar 2017 Unreliable methotrexate safety information and guidance 2 2 20 Feb 2026 Unreliable military-exercise heat-risk requirements and controls 2 1 1 Nov 2019 Unreliable monitoring and emergency response during detainee transport 2 5 20 Feb 2026 Unreliable MOSOVO management of sexual and violent offenders 2 8 11 Mar 2025 Unreliable multi-agency control of home fire risks for vulnerable residents 2 6 3 Oct 2024 Unreliable multidisciplinary and interagency care planning for mental-health relapse 2 4 25 Feb 2022 Unreliable Mycobacterium Chimaera infection-risk information and notification 2 5 29 Jun 2023 Unreliable notification of domestic abuse victims about bail and protective-order decisions 2 8 18 Nov 2020 Unreliable nutrition and hydration safety governance 2 3 28 Nov 2022 Unreliable Occupational Health support before and during assessment 2 4 14 Jan 2025 Unreliable Ofsted inspection processes 2 3 12 Dec 2023 Unreliable operation and access of the BadgerNet clinical information system 2 6 9 Nov 2023 Unreliable operation of the Oxevision patient-monitoring system 2 2 8 Feb 2026 Unreliable Oramorph storage and handling controls 2 4 30 Dec 2022 Unreliable out-of-hours access to hospital theatres 2 4 26 Nov 2013 Unreliable oxygen concentrator safety controls 2 5 26 May 2016 Unreliable oxygen humidifier safety controls 2 8 3 Feb 2017 Unreliable patient whiteboard information systems 2 6 17 Dec 2013 Unreliable PAT testing and safety assurance for electrical equipment 2 3 17 Nov 2025 Unreliable place-of-safety arrangements for intoxicated or mentally unwell people at immediate risk 2 6 26 Feb 2021 Unreliable plaster-cast care and management 2 4 12 Dec 2017 Unreliable police access to safety-critical CCTV information 2 4 8 May 2024 Unreliable police and ambulance coordination for patient transport assistance 2 5 20 Aug 2025