Safety concerns raised by coroners

Inadequate safety controls for high-risk machinery work 6 12 26 Jun 2025 Inadequate safety guidance for managing hazards in rented residential properties 6 13 11 Dec 2024 Inadequate staff competence to recognise and respond to acutely unwell patients 6 21 7 Apr 2025 Inadequate water rescue provision for recreational water activities 6 12 27 Feb 2023 Unclear responsibility for prescribing and medication advice 6 11 9 Dec 2025 Uncontrolled dangerous currents affecting swimmers 6 9 3 Jul 2024 Unreliable access to clinically necessary dietetic assessment and support 6 9 5 Jun 2026 Unreliable access to ligature cutters for frontline responders 6 10 10 Apr 2024 Unreliable access to required social-worker support 6 13 29 Jan 2025 Unreliable ambulance-service computer systems for safety-critical information 6 20 27 Jan 2020 Unreliable care and follow-up for identified fractures 6 5 18 Jun 2025 Unreliable communication to referrers about referral service access and expectations 6 12 24 Nov 2023 Unreliable consent controls for safety-critical information sharing 6 13 31 Jan 2025 Unreliable coronial autopsy governance and processes 6 17 25 Nov 2025 Unreliable dementia care and management 6 13 6 Sep 2024 Unreliable determination and recording of causes of death 6 18 10 Mar 2026 Unreliable dysphagia care and management 6 8 22 May 2026 Unreliable electronic medication-system controls for safe prescribing and administration 6 13 7 Apr 2026 Unreliable escalation and referral in eating disorder care 6 23 7 Jan 2026 Unreliable guidance and closure controls for unsafe pedestrian paths 6 11 9 Feb 2026 Unreliable guidance for medication continuation and discontinuation decisions 6 8 7 Jan 2025 Unreliable interpretation of cardiac electrical recordings 6 16 9 May 2025 Unreliable investigation and escalation of safety-related professional misconduct 6 9 28 Jun 2023 Unreliable investigation of serious infection causes 6 13 10 Mar 2026 Unreliable management of specialist modified diets 6 9 10 May 2024