Safety concerns raised by coroners

Ineffective communication during medical emergencies 42 71 26 May 2026 Unreliable arrangement and communication of patient appointments and follow-up 42 65 23 Oct 2025 Failure to ensure essential clinical equipment and supplies are available and serviceable 41 70 8 May 2026 Insufficient mental health service capacity for timely patient care 40 46 24 Oct 2025 Failure to act appropriately on safeguarding referrals and notices 39 76 5 Mar 2026 Failure to maintain clear clinical responsibility for patient care 39 77 8 Jun 2026 Inadequate management of patients' nutrition and hydration needs 39 65 24 Feb 2026 Unreliable escalation of abnormal clinical observations 39 55 17 Nov 2025 Failure to call an ambulance promptly when emergency assistance is required 37 47 27 Jan 2026 Failure to obtain relevant collateral information from family and social supports 37 69 5 Mar 2026 Failure to recognise impaired decision-making capacity in care decisions 37 74 10 Mar 2026 Unreliable shift handover processes 36 65 26 Jun 2026 Unreliable urgent mental health referral and assessment pathways 36 45 4 Mar 2026 Delays in consultant review of patients 35 41 27 Feb 2026 Failure to involve families and carers in discharge planning and decisions 35 51 7 Nov 2025 Failure to reliably refer patients to required specialist services 35 54 4 Feb 2026 Unreliable assessment and recording of patients’ mental capacity 35 74 10 Mar 2026 Unreliable escalation policy for care concerns 35 40 31 Mar 2026 Unsafe interoperability between prison custody and healthcare procedures 35 54 20 May 2026 Failure of police operational communications to reliably share safety-critical information 34 55 17 Mar 2026 Failure to ensure safe post-discharge arrangements for vulnerable patients and residents 34 46 14 Apr 2026 Failure to reliably supervise and monitor residents in care accommodation 34 50 21 May 2026 Inadequate and unreliable public-road street lighting 34 37 1 Dec 2025 Inadequate road markings for road-user safety 34 40 2 Feb 2026 Inadequate supervision and monitoring of prisoners 34 40 29 Jun 2026