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
Inadequate professional training for recognising and responding to domestic abuse
8
20
5 Mar 2026
Inadequate safety planning for acute mental-health deterioration and suicide risk
8
8
27 May 2026
Inadequate staff training and familiarisation in defibrillator use
8
20
8 May 2026
Inadequate university mental-health support systems for students
8
16
31 Jan 2025
Inadequate window fall-prevention controls in residential accommodation
8
11
21 Jun 2024
Incomplete clinical guidance for venous thromboembolism assessment and management
8
9
12 Aug 2024
Inconsistent and unclear prescribing guidance
8
19
3 Sep 2025
Inconsistent implementation of suicide-prevention systems
8
13
8 Aug 2025
Insufficient acute hospital capacity for patients requiring admission
8
14
3 Nov 2025
Insufficient age-appropriate mental health provision for young people transitioning to adulthood
8
13
29 Apr 2026
Insufficient clinical workload capacity for completing important patient-care tasks
8
10
25 Jun 2026
Insufficient specialist support for eating-disorder patients
8
19
14 Feb 2024
Insufficient staffing cover for mental health services during absences
8
12
27 Sep 2024
Unclear roles and pathways for community mental-health services
8
12
8 Aug 2025
Unreliable capture and onward use of telephone helpline information
8
16
16 Jun 2026
Unreliable case allocation and resolution of allocation disputes
8
13
4 Sep 2025
Unreliable communication of discharge medication information to care staff
8
14
4 Mar 2024
Unreliable complex case management
8
18
15 May 2026
Unreliable contact arrangements for urgent clinical advice
8
11
26 May 2026
Unreliable emergency-service incident grading and response-time coordination
8
17
23 Mar 2026
Unreliable fatigue controls for prolonged safety-critical shifts
8
17
21 Mar 2024
Unreliable guidance and communication for safety risk assessments
8
15
10 Apr 2025
Unreliable implementation of autism care and support services
8
10
10 Dec 2023
Unreliable intrapartum CTG interpretation and escalation
8
12
19 May 2025
Unreliable management of clinical waiting lists
8
15
1 May 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