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
Unreliable officer access to and familiarisation with required operational instructions
7
18
14 Sep 2023
Unreliable patient identification during healthcare contacts
7
9
25 Sep 2025
Unreliable police pursuit management and authorisation
7
8
24 Oct 2025
Unreliable pre-operative assessment arrangements delaying or compromising surgery
7
7
10 May 2022
Unreliable prison cell-hatch observation of prisoners
7
13
29 Jun 2026
Unreliable prison roll-check procedures
7
10
18 Jul 2025
Unreliable product safety recall and remediation processes
7
25
11 Jan 2023
Unreliable recording and retrieval of safety-critical risk information on the PNC
7
14
16 Dec 2025
Unreliable retention of biological samples for postmortem investigation
7
19
25 Nov 2025
Unreliable safety controls for temporary traffic management schemes
7
16
6 Apr 2026
Unreliable senior oversight of safety incident reviews
7
13
30 Jan 2025
Unreliable therapeutic engagement in mental health care
7
15
24 Oct 2025
Unsafe individualised treatment planning for acute mental health risk
7
11
1 Jun 2026
Unsafe operation of prison segregation procedures
7
14
27 Jan 2023
Unsafe road width for vehicle passage
7
9
3 Feb 2022
Unsafe transition and continuity of care from child to adult healthcare
7
7
12 Aug 2025
Domestic abuse risk assessment is unreliable
6
18
2 May 2026
Failure of fire detection systems to reliably alert and trigger emergency response
6
21
16 Jun 2026
Failure of neurosurgical referral systems to provide timely specialist advice
6
16
18 Jan 2024
Failure of police post-incident performance learning and remediation
6
13
29 Sep 2025
Failure to account for autistic presentation in mental health assessment and care
6
16
5 Jul 2022
Failure to assess risks before hazardous work tasks
6
14
2 Mar 2020
Failure to control risks posed by care-home residents to themselves and others
6
9
1 Aug 2025
Failure to ensure custody staff understand and apply detention procedures
6
13
25 Jul 2025
Failure to ensure police custody staff are competent for safe custody-suite work
6
12
27 Mar 2024
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