Safety concerns raised by coroners

Unsafe management of operational protocol changes 10 14 4 Oct 2023 Unsafe recognition and response to significantly abnormal blood pressure 10 20 3 Jun 2026 Failure of echocardiography services to provide timely diagnostic assessment and follow-up 9 16 10 Mar 2026 Failure to assure reliable patient observations 9 13 24 Oct 2025 Failure to ensure care staff can initiate appropriate emergency calls 9 18 27 Feb 2023 Failure to ensure substance vendors recognise suicide and self-harm misuse risks 9 3 23 May 2025 Failure to maintain a shared clinical overview of patients' changing concerns 9 14 11 Nov 2025 Failure to make previous self-harm and suicide-risk information available for safety assessments 9 16 21 Oct 2025 Failure to provide effective regulatory oversight of providers serving vulnerable people 9 16 26 Mar 2026 Failure to provide requested on-call clinical review 9 11 19 Dec 2023 Failure to recognise and respond to prisoners’ disability and neurodiversity-related needs 9 24 30 May 2025 Failure to reliably escalate patient safety concerns to primary care 9 16 4 Nov 2024 Failure to reliably report deaths to coroners 9 35 25 Nov 2025 Inadequate CCTV coverage and monitoring in custodial settings 9 19 20 Dec 2019 Inadequate competence in mental health assessment 9 21 13 Mar 2025 Inadequate controls for carbon monoxide exposure 9 26 31 Mar 2026 Inadequate controls for icy and slippery surfaces 9 13 6 Jul 2026 Inadequate cycle-lane provision for cyclist safety 9 11 2 Sep 2022 Inadequate paramedic training for safe emergency assessment and treatment 9 27 16 Sep 2025 Inadequate sprinkler protection in residential accommodation 9 9 16 Jun 2026 Insufficient prison staffing capacity for safe regime operation and incident response 9 9 24 Mar 2026 Insufficient staffing capacity for required one-to-one patient support 9 14 24 Apr 2026 Insufficient tissue viability service capacity and access 9 25 25 Sep 2025 Unclear healthcare and police responsibilities for safety-critical action 9 38 7 Apr 2025 Unreliable activation of emergency medical response teams 9 12 23 Oct 2025