Safety concerns raised by coroners

Unreliable safety assessment during vulnerable-person home visits 3 7 3 Oct 2018 Unreliable safety controls for shooting-range operations 3 3 10 Jun 2021 Unreliable safety review and escalation when clinical appointments are delayed or cancelled 3 10 25 Mar 2024 Unreliable second prison reception health screening 3 4 13 Jul 2017 Unreliable security alarms for detecting insecure exits and access 3 7 31 Jul 2017 Unreliable social-care case review and closure decisions 3 3 14 Nov 2023 Unreliable specialist support for reducing and withdrawing from prescribed opioids 3 5 3 Mar 2026 Unreliable stability controls for wheeled furniture in patient-care areas 3 5 6 Jun 2023 Unreliable supervision and competence assurance for trainee medical staff 3 6 13 Jan 2025 Unreliable tracking and completeness checking of faxed referrals and information 3 7 14 May 2018 Unreliable tracking and transfer of completed mental health-related forms 3 18 6 Jul 2021 Unreliable transfer of cases between police forces 3 4 19 Oct 2025 Unreliable transfer of hospital discharge information to prison healthcare 3 3 10 Aug 2016 Unreliable use of Mental Health Act holding powers 3 9 19 Dec 2022 Unreliable vehicle reversing safety controls around pedestrians 3 1 19 Jul 2021 Unsafe administration of intravascular contrast media 3 7 14 Mar 2025 Unsafe amiodarone treatment management 3 4 20 Mar 2022 Unsafe bus stop siting and pedestrian access 3 5 10 Apr 2019 Unsafe catheterisation practice 3 4 26 Sep 2017 Unsafe coordination of thrombolysis care 3 6 14 Nov 2025 Unsafe endotracheal tube management 3 11 6 Sep 2021 Unsafe feticide and post-feticide care 3 5 3 Nov 2021 Unsafe home-visit policies for clinical and personal-safety decisions 3 4 29 Aug 2019 Unsafe implementation of early discharge pathways 3 4 7 Jan 2016 Unsafe implementation of Right Care, Right Person attendance decisions 3 4 1 Dec 2025