Safety concerns raised by coroners

Failure to ensure staff competence in fire safety and evacuation 6 19 19 Apr 2026 Failure to keep historical risk information accessible for later risk assessment 6 10 21 May 2024 Failure to maintain adequate visibility for patient monitoring 6 8 7 Jul 2023 Failure to provide emergency responders with readily accessible safety-critical patient information 6 13 23 Jan 2026 Failure to provide indicated antibiotic prophylaxis 6 10 22 Jan 2024 Failure to provide required mealtime supervision 6 12 19 Feb 2026 Failure to provide timely and competent mental health assessment after self-harm 6 15 26 Mar 2024 Failure to provide timely and reliable carer assessments 6 8 17 Apr 2025 Failure to provide timely clinical review during ambulance call handling 6 10 28 Oct 2025 Failure to recognise breathing emergencies during police encounters 6 12 7 Oct 2025 Failure to recognise physical illness in mental health patients 6 6 12 Aug 2024 Failure to reliably recognise and respond to drug and alcohol withdrawal in custody 6 15 20 Feb 2026 Failure to reliably verify medication information during care assessments 6 16 19 Mar 2026 Failure to review relevant care documentation before providing care 6 10 6 Jun 2024 Failure to secure suitable accommodation for people released from prison 6 10 27 Jan 2025 Failure to secure timely suitable alternative accommodation for vulnerable people 6 7 9 Mar 2026 Inadequate child safeguarding assessment 6 20 7 Feb 2025 Inadequate contingency planning for safe patient care during staffing shortages 6 10 4 Feb 2026 Inadequate fire detection and emergency notification for vulnerable people in housing 6 11 26 Apr 2022 Inadequate formal health and safety training for responsible staff 6 14 22 Feb 2024 Inadequate management of smoking-related fire risks in vulnerable people 6 10 3 Oct 2024 Inadequate pastoral support systems for identifying and responding to welfare concerns 6 9 10 Jul 2024 Inadequate professional registration and fitness-to-practise safeguards 6 13 28 Dec 2025 Inadequate recognition controls for atypical aortic emergencies 6 9 14 Oct 2025 Inadequate road-traffic-collision reporting for highway safety management 6 8 23 Jun 2025