Safety concerns raised by coroners

Incomplete recording of legally relevant relative details in mental-health records 3 4 29 May 2025 Inconsistent paediatric sepsis recognition and response guidance 3 5 28 Feb 2020 Insufficient and unsafe crisis-house provision for patients needing crisis care 3 3 20 Feb 2025 Insufficient dedicated substance-misuse support in custody 3 10 21 Oct 2019 Insufficient dietetic staffing capacity for timely patient care 3 4 3 Jun 2024 Insufficient driver experience for safe vehicle control 3 4 4 Jul 2024 Insufficient health visitor capacity to support vulnerable families and young children 3 9 19 Mar 2025 Insufficient hospital theatre capacity for timely surgery 3 2 10 Dec 2024 Insufficient out-of-hours specialist stroke support 3 5 4 Feb 2026 Insufficient resourcing of prison self-harm prevention functions 3 5 20 May 2026 Insufficient workload capacity for timely clinical record completion 3 5 17 May 2021 Social media features failing to control amplification of harmful content 3 13 8 Dec 2025 Unclear accountability for safety risk assessments 3 7 24 Oct 2022 Unclear allocation of safety responsibilities at organised public events 3 4 10 Apr 2025 Unclear responsibility for Mental Health Act emergency procedures 3 15 8 Sep 2019 Unreliable access to and navigation of veteran support services 3 3 31 Jan 2025 Unreliable access to specialist pain care for people with chronic pain 3 5 17 Jun 2022 Unreliable ambulance stand-down decisions 3 4 25 Jun 2018 Unreliable and delayed access to interpreters for safety-critical communication 3 9 7 Oct 2025 Unreliable annual safety inspection processes 3 4 24 Jan 2024 Unreliable antidote treatment arrangements for toxic-substance poisoning 3 10 10 Apr 2026 Unreliable aspiration assessment and prevention 3 4 18 Jun 2025 Unreliable assessment of medication concordance in mental health care 3 5 17 Feb 2025 Unreliable assessment of when physiological observations are needed 3 3 31 Oct 2025 Unreliable authorisation and documentation of departures from clinical plans and standards 3 3 25 Apr 2024