Safety concerns raised by coroners

Failure to provide continuous access to appropriate mental health care 3 6 12 Dec 2019 Failure to provide criminal courts with relevant vulnerability and risk information 3 7 11 Mar 2025 Failure to provide feedback and learning to clinicians after safety-relevant clinical errors 3 3 5 Dec 2023 Failure to provide oral care to vulnerable patients 3 2 6 Dec 2023 Failure to provide prompt life-saving response to hanging casualties 3 5 19 Feb 2024 Failure to provide protective mechanisms for children at risk from adults 3 8 1 May 2026 Failure to provide required daily mental-health team visits 3 4 9 Apr 2019 Failure to provide timely and reliable fresh-eyes reviews in maternity care 3 3 3 Apr 2022 Failure to provide timely psychiatric review through home treatment teams 3 4 19 Sep 2019 Failure to provide timely treatment for constipation and impacted faeces 3 5 12 Aug 2025 Failure to reassess safety risks during significant mental-health medication changes 3 3 19 Dec 2025 Failure to recognise and act on deterioration in vulnerable adults’ living circumstances and support needs 3 6 28 May 2021 Failure to recognise and adequately assess clinically significant psychotic symptoms 3 5 15 Mar 2023 Failure to recognise and manage post-endoscopy complications 3 3 21 Jun 2021 Failure to recognise distress and increased risk communicated through behaviour 3 11 4 May 2024 Failure to recognise dying patients and initiate end-of-life care 3 1 28 Oct 2016 Failure to recognise medication-related pulmonary toxicity 3 8 19 Aug 2025 Failure to reliably allocate key workers to mental health service users 3 5 21 Nov 2022 Failure to reliably apply PSI 64/2011 mental-health risk guidance 3 2 1 Aug 2024 Failure to reliably arrange and complete clinically required biopsies 3 5 23 Dec 2024 Failure to reliably communicate clinicians’ identities and clinical grades 3 7 10 Aug 2025 Failure to reliably complete My Safety Plans 3 5 1 Sep 2025 Failure to reliably identify and refer vulnerable people at risk of fire 3 7 3 Aug 2021 Failure to reliably identify foreign convictions 3 5 23 Sep 2020 Failure to reliably investigate metabolic causes of acute clinical presentations 3 9 4 Mar 2026