Safety concerns raised by coroners

Failure to verify medication and dose before dispensing 4 6 17 Dec 2025 Inadequate assessment of causes and risks of mental health relapse 4 10 6 Feb 2026 Inadequate assurance and review of commissioned care services and care packages 4 5 2 Apr 2026 Inadequate care and supervision provision for prisoners with complex needs 4 5 24 Nov 2025 Inadequate central-reservation controls for errant vehicles 4 5 2 Jun 2025 Inadequate communication of opioid toxicity risks 4 12 31 Mar 2025 Inadequate control and visibility of hazardous kerb edges 4 4 30 Apr 2025 Inadequate controls on the sale of lithium-ion e-bike batteries and chargers 4 3 5 Aug 2025 Inadequate controls preventing dangerous vehicle movements between slip roads and carriageways 4 10 16 Apr 2025 Inadequate food-hygiene controls in care settings 4 8 12 Aug 2025 Inadequate interim care for patients awaiting gender-identity treatment 4 6 30 Apr 2024 Inadequate lifejacket safety controls for watercraft users 4 5 20 Dec 2024 Inadequate patient information for surgical procedures 4 5 24 Sep 2019 Inadequate prison physical security controls preventing transfer of drugs and contraband 4 7 4 Feb 2026 Inadequate safety glazing in doors 4 4 24 Oct 2023 Inadequate suicide-prevention signage at public locations 4 4 13 Jan 2020 Inadequate surveillance of swimmers and water users 4 4 27 Feb 2023 Inadequate trauma-informed mental health services for people affected by trauma and domestic abuse 4 7 5 Sep 2025 Inadequate vehicle restraint protection at hazardous edges 4 7 6 Jul 2026 Incomplete cardiovascular risk information for clinical assessment and investigation 4 9 6 Jun 2025 Insufficient assessment of patients’ current drug use before drug treatment 4 7 1 Aug 2019 Insufficient CAMHS staffing capacity and competence for safe care 4 9 30 Apr 2024 Insufficient CCTV monitoring of access to high-risk locations 4 9 3 Apr 2025 Insufficient community-based alternatives to psychiatric hospital admission 4 7 6 Feb 2026 Insufficient critical care bed capacity 4 8 16 Jun 2025