Safety concerns raised by coroners

Unreliable use of the MARAC process for domestic abuse risk management 4 13 18 Nov 2020 Unreliable wheelchair fall-prevention controls 4 5 16 Dec 2021 Unsafe agricultural tractor and trailer safety arrangements 4 8 26 Sep 2025 Unsafe cervical-collar provision and management 4 5 28 Aug 2025 Unsafe loading and unloading of heavy vehicle loads 4 6 26 Jun 2023 Unsafe management of pneumothorax 4 8 17 Jan 2023 Unsafe management of upper gastrointestinal bleeding 4 9 18 Dec 2023 Unsafe operation of door-closing systems 4 7 12 Dec 2016 Unsafe patient cannulation 4 10 14 Nov 2023 Unsafe police conveyance of mental health patients 4 11 25 Jul 2025 Unsafe prescribing for patients consuming excessive alcohol 4 6 9 Aug 2022 Unsafe recognition and management of hypoglycaemia 4 8 30 Jul 2025 Unsafe shared cycle and pedestrian route design 4 5 4 Nov 2024 Unsafe tractor and trailer coupling systems 4 8 26 Nov 2024 Unsafe use and management of patient slings 4 12 18 Sep 2023 Unsafe vehicle lighting and signalling controls 4 8 9 Dec 2021 Clinical layouts failing to support full patient oversight 3 4 30 Sep 2022 Failure of electronic prescription systems to support reliable prescribing and dispensing 3 6 26 Jun 2023 Failure of microbiology testing services to provide timely and reliable results 3 3 5 Jun 2026 Failure to adapt academic decisions and support to student vulnerability 3 4 10 Jul 2024 Failure to assess and respond to limb viability concerns 3 3 18 Jun 2025 Failure to assess and respond to mental-health risks arising during child protection and care proceedings 3 13 30 May 2024 Failure to assess risks before introducing new work procedures 3 3 12 Feb 2025 Failure to control blind-cord strangulation risks in residential properties 3 3 26 Jul 2022 Failure to control bullying in institutional settings 3 4 8 Dec 2025