Safety concerns raised by coroners

Inadequate controls for fire risks from paraffin-containing emollients 7 23 12 Aug 2025 Inadequate pre-release risk assessment for people leaving custody 7 8 12 Aug 2024 Inadequate regulatory oversight of organised public events 7 14 10 Apr 2025 Incomplete and inadequately documented clinical assessments of children 7 15 30 Mar 2026 Incomplete consideration of relevant factors in falls risk assessments 7 14 17 Nov 2023 Unreliable access to appropriate addiction support 7 11 30 Apr 2021 Unreliable access to physical health specialist input for mental health inpatients 7 11 5 Jun 2026 Unreliable access to timely autism assessment 7 16 5 Feb 2026 Unreliable algorithmic triage of unwell patients 7 9 3 Sep 2025 Unreliable assessment of whether a person is breathing 7 12 8 Jan 2026 Unreliable category 3 ambulance assessment and response arrangements 7 9 6 Jan 2026 Unreliable chest drain insertion and management 7 14 27 Jul 2020 Unreliable clinical decisions about when CT scanning is needed 7 11 22 Dec 2025 Unreliable clinical management of medication overdose and toxicity 7 19 17 Nov 2025 Unreliable consultant attendance when clinically required 7 14 30 Aug 2024 Unreliable controls for restricting dangerous items in inpatient care 7 19 21 Apr 2023 Unreliable coordination of radiology services between healthcare teams 7 10 20 Nov 2024 Unreliable critical-care outreach for deteriorating patients 7 10 16 Jun 2025 Unreliable CT scan request and escalation processes 7 10 26 Feb 2026 Unreliable EMIS clinical information and prescribing functions 7 10 19 Aug 2025 Unreliable hospital bed management and allocation processes 7 17 23 Nov 2023 Unreliable information sharing for prison-to-community discharge coordination 7 21 6 Feb 2026 Unreliable management of nil-by-mouth restrictions 7 8 22 May 2026 Unreliable mode-of-delivery decision-making 7 10 15 Sep 2023 Unreliable offender risk assessment and review 7 23 26 Jul 2024