Safety concerns raised by coroners

Unsafe on-call consultant rota arrangements 3 3 14 Sep 2018 Unsafe operational pressure in emergency departments 3 3 3 Oct 2024 Unsafe operation of patient hoists 3 7 17 Aug 2023 Unsafe planning and safety management of organised youth trips 3 2 7 Feb 2020 Unsafe recognition and management of subarachnoid haemorrhage 3 6 5 Dec 2025 Unsafe self-discharge decision-making 3 2 25 Sep 2023 Unsafe split-site hospital service arrangements 3 7 3 Jun 2025 Unsafe transfer and connection of portable oxygen supplies 3 3 22 Mar 2019 Unsafe work in proximity to moving heavy vehicles and machinery 3 3 2 Aug 2024 Vehicle approval failing to control serious safety risks 3 4 19 May 2026 Failure of benefits administration to account for recognised vulnerabilities 2 1 22 Jan 2026 Failure of private hospitals to assure safe oversight of doctors' practice limitations 2 2 18 Mar 2026 Failure of SECAMBS to respond to calls within target timeframes 2 2 26 Jun 2023 Failure of the CSRA policy to protect prisoners from relevant safety risks 2 4 15 Dec 2025 Failure of The Scouts Association to oversee local health and safety execution 2 8 22 Feb 2024 Failure to acknowledge and act on employee safety concerns 2 3 12 Feb 2025 Failure to adapt healthcare communication for neurodivergent patients and parents 2 4 27 May 2026 Failure to align product promotion with current safety information 2 6 19 Apr 2021 Failure to assess safety risks before using potentially dangerous equipment 2 2 26 Jun 2023 Failure to assure clinical information communication processes 2 4 29 Mar 2017 Failure to commission care for people with overlapping mental-health and complex needs 2 4 6 May 2026 Failure to communicate enteral-tube bore restrictions to end users 2 6 19 Apr 2021 Failure to communicate the serious harms of ketamine 2 3 19 Aug 2025 Failure to conduct multidisciplinary risk assessments for high-risk prisoners 2 4 20 Apr 2020 Failure to conduct safety debriefs after serious incidents 2 4 14 Oct 2024