Safety concerns raised by coroners

Unreliable bowel monitoring and charting 3 4 14 Feb 2017 Unreliable cardiology pathways for specialist review 3 5 6 Mar 2026 Unreliable care and protection arrangements for people with chronic alcohol dependence 3 4 13 Oct 2025 Unreliable chest X-ray referral and ordering 3 5 6 Feb 2024 Unreliable clinical review of observation charts 3 4 2 Dec 2023 Unreliable communication of care-review meeting outcomes 3 4 2 May 2025 Unreliable Consultant-to-Consultant referral processes 3 7 23 Jun 2025 Unreliable coordinated review of vulnerable residents’ support needs 3 5 24 Nov 2024 Unreliable coordination and outcome follow-up after tertiary-centre transfer 3 6 2 Mar 2021 Unreliable coordination and scheduling of district nursing visits 3 5 22 Feb 2021 Unreliable coordination of cancer diagnosis and treatment 3 6 4 Jul 2024 Unreliable coordination of specialist learning-disability support in healthcare 3 6 14 Jul 2025 Unreliable CRIS investigation information and review processes 3 4 21 Jan 2022 Unreliable crisis telephone access for prisoners 3 6 20 Mar 2026 Unreliable CTG equipment safety controls 3 8 14 Oct 2021 Unreliable CTPA investigation and follow-up 3 4 7 Mar 2022 Unreliable detection and monitoring of prescription errors 3 6 17 Nov 2025 Unreliable district nursing assessment and monitoring of patients 3 7 6 Jul 2017 Unreliable duty system arrangements for safe clinical coverage 3 6 20 Oct 2023 Unreliable emergency arrangements for assisting third parties 3 12 16 Jun 2026 Unreliable emergency evacuation arrangements for people requiring assisted removal 3 4 14 Jul 2023 Unreliable emergency forced-entry arrangements 3 4 8 Jul 2025 Unreliable emergency management of breech birth 3 14 16 Sep 2025 Unreliable emergency oxygen administration 3 7 28 Apr 2023 Unreliable emergency water-rescue procedures and equipment 3 7 7 Sep 2023