Safety concerns raised by coroners
Explore concerns raised in Prevention of Future Deaths (PFD) reports.
Recurring concerns bring together individual concerns from different reports that describe the same underlying safety problem.
1,669 recurring concerns
Concern
Trend
Reports
Recipients
Latest report
Failure to reliably apply Mental Capacity Act principles in care decisions
10
16
25 Nov 2025
Failure to reliably escalate suicidal intent information
10
17
18 Jun 2024
Failure to reliably review clinical records for safety deficiencies
10
14
16 Jun 2026
Inadequate controls for bleeding risk in patients taking antithrombotic medication
10
11
24 Apr 2024
Inadequate road drainage allowing hazardous surface water to remain on carriageways
10
10
30 Dec 2022
Inadequate roadside vehicle-restraint barriers
10
11
18 Jul 2025
Inadequate staff training for managing complex care needs
10
30
25 Apr 2024
Insufficient radiology workforce capacity for timely imaging and interpretation
10
10
26 May 2026
Out-of-area mental health placements failing to provide effective continuity of care and support
10
13
18 Oct 2024
Toxicity risks from excessive or combined medication use
10
16
29 Dec 2025
Unreliable accuracy of safety-review findings and conclusions
10
20
30 Jan 2025
Unreliable clinical second-opinion processes
10
15
27 Feb 2026
Unreliable completion and transfer of Prisoner Escort Records
10
22
21 Jun 2023
Unreliable crisis-team access and communication
10
12
28 May 2025
Unreliable end-of-life care decision-making and consultation
10
13
2 Feb 2026
Unreliable highway safety risk assessment and remedial-work prioritisation
10
17
7 May 2024
Unreliable laboratory notification of safety-critical problems and results
10
16
6 Feb 2026
Unreliable lawful decision-making for mental health patient detention and return
10
15
28 Oct 2025
Unreliable patient-monitoring alarm systems
10
16
11 Jun 2026
Unreliable police investigative evidence gathering
10
22
13 Jan 2026
Unreliable safety risk assessments for prisoners
10
17
15 Dec 2025
Unreliable telecare service safety controls
10
28
4 Apr 2025
Unreliable tracking and follow-up of outpatient appointments
10
15
23 Oct 2025
Unsafe confidentiality and information-sharing arrangements in service mental health care
10
12
29 Nov 2024
Unsafe implementation and oversight of service changes
10
20
14 Oct 2025
Recurring concerns bring together reports that describe the same underlying safety problem. Open one to compare the individual concerns and original wording.
Data last updated 7 September 2026