Safety concerns raised by coroners

Insufficient emergency control-room staffing capacity 4 5 20 Dec 2023 Insufficient hospital capacity to maintain timely care during demand surges 4 5 23 Nov 2023 Insufficient probation officer staffing capacity for safe casework 4 9 26 Jul 2024 Insufficient suitable acute mental-health settings for neurodiverse patients 4 3 5 Feb 2025 Insufficient suitable supported accommodation for vulnerable people 4 11 28 May 2021 Safeguarding systems failing to identify and respond to neglect 4 6 4 Jul 2023 Temporary clinical staff may lack required safety policies and procedures 4 4 16 Oct 2024 Uncontrolled hazards from defective electrical wiring and installations 4 5 3 Feb 2021 Unreliable access controls for residential accommodation 4 6 4 Mar 2024 Unreliable access to clinically required medication during supply shortages 4 6 31 Mar 2025 Unreliable activation of trauma response for serious injuries 4 6 7 Mar 2022 Unreliable alarm controls for oxygen therapy 4 7 15 Jan 2026 Unreliable alignment between police guidance and legal powers for safety-critical interventions 4 16 24 Apr 2026 Unreliable allocation and completion of night-shift care tasks 4 8 13 Sep 2024 Unreliable ambulance-to-emergency-department patient-information handover 4 14 26 Nov 2021 Unreliable anticoagulation reversal decisions 4 4 30 Mar 2026 Unreliable CAD systems for safety-critical information 4 9 10 Mar 2026 Unreliable capnography use during intubation and resuscitation 4 9 13 Jun 2024 Unreliable child safeguarding referral processes 4 16 3 Sep 2025 Unreliable communication between pharmacies and clinical teams 4 11 18 Aug 2023 Unreliable communication with cardiology teams about patient care 4 6 6 Mar 2026 Unreliable constant-observation arrangements for detained persons 4 9 7 Apr 2026 Unreliable controlled-drug custody, documentation and audit controls 4 6 25 Feb 2020 Unreliable court-to-prison transfer information 4 12 21 Oct 2021 Unreliable criminal-conviction vetting for safety-sensitive roles 4 12 13 Feb 2023