Safety concerns raised by coroners

Inadequate GP consultation provision for safe patient assessment 17 17 18 Dec 2025 Inadequate physical separation between pedestrians and vehicular traffic 17 18 8 Jun 2026 Unclear accountability for health and safety controls 17 42 28 May 2025 Unclear and unreliable GP access and referral pathways 17 29 20 Apr 2026 Unreliable ambulance dispatch and resource-allocation controls 17 15 30 Jan 2025 Unreliable coordination and escalation between care providers and mental health services 17 32 22 Dec 2025 Unreliable custody handovers 17 33 30 Mar 2026 Unreliable emergency response arrangements in care homes 17 25 31 Oct 2025 Unreliable gathering of witness evidence for formal investigations 17 25 6 Feb 2026 Unreliable interpretation of diagnostic imaging 17 25 31 Mar 2026 Unreliable inter-specialty communication for complex patient care 17 34 22 Dec 2025 Unreliable Mental Health Act detention arrangements 17 44 28 Oct 2025 Unreliable safety monitoring and guidance for clozapine treatment 17 25 14 Jan 2026 Unsafe assignment of staff without the required qualifications or competence to care work 17 28 2 Feb 2026 Unsafe discharge, closure or withdrawal of mental health services 17 27 11 Jan 2026 Unsafe emergency-department crowding leaving patients without appropriate clinical space 17 18 18 Jun 2026 Unsafe operation of Section 136 mental health assessment and detention procedures 17 36 24 Apr 2026 Failure of emergency response leadership and coordination 16 31 26 Aug 2025 Failure to involve families and carers in safety-critical care decisions 16 32 2 May 2026 Failure to prevent public access to closed or restricted hazardous sites 16 20 6 Mar 2026 Failure to provide adequate and accessible staff induction 16 26 19 Oct 2025 Failure to reliably communicate clinically significant patient observations to medical staff 16 23 27 Oct 2023 Inadequate controls on the sale and online access to highly toxic substances 16 10 9 Jul 2025 Inadequate training and competence assurance for carers providing care 16 23 8 Jan 2026 Unreliable Community Mental Health care access and discharge processes 16 31 18 Nov 2025