Safety concerns raised by coroners

Unsafe road design and layout 34 35 2 Feb 2026 Excessive waiting times for NHS mental health services 33 29 4 Mar 2026 Failure of case monitoring to identify cases requiring follow-up 33 60 4 Mar 2026 Failure to incorporate relevant clinical history and diagnoses into care decisions 33 37 27 May 2026 Failure to integrate mental health services across care settings 33 59 14 Jan 2026 Failure to maintain safe hospital patient flow 33 28 18 Jun 2026 Telephone triage that is unreliable and can delay necessary care 33 45 11 May 2026 Unreliable emergency response to patient collapse 33 51 26 May 2026 Unreliable on-site emergency medical and first-aid response arrangements 33 60 20 Feb 2026 Unsafe operation of multidisciplinary clinical meetings 33 53 27 May 2026 Failure to provide required medication promptly when clinically needed 32 39 17 Jun 2026 Failure to retain safety-critical source records and evidence 32 61 20 May 2026 Failure to reliably conduct clinically required medication reviews 31 49 8 Feb 2026 Inadequate informed-consent processes for medical treatment 31 43 28 Dec 2025 Insufficient social and community care provision to meet care and discharge needs 31 32 18 Jun 2026 Failure to ensure staff competence in resuscitation 30 48 20 Feb 2026 Failure to provide continuity of care staffing 30 34 8 Feb 2024 Failure to secure and control medication 30 55 17 Dec 2025 Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crises 30 48 2 Feb 2026 Failure to ensure timely and appropriate Mental Health Act assessment 29 53 13 Mar 2025 Failure to reliably monitor patient fluid balance 29 38 22 Dec 2025 Failure to reliably transfer medical records between healthcare organisations 29 48 20 Oct 2025 Inadequate safety-netting advice for patients and carers 29 36 10 Nov 2025 Medication quantity controls failing to prevent unsafe access to excessive amounts 29 42 27 Oct 2025 Unreliable community Home Treatment Team care pathways 29 40 27 May 2026