Safety concerns raised by coroners

Failure to control safety risks from tall-building developments 2 4 4 Jan 2016 Failure to control safety risks in spoil-heap management and removal operations 2 3 31 Oct 2018 Failure to disseminate safeguarding protocols and learning reliably 2 5 1 May 2026 Failure to ensure care-home managers meet statutory registration requirements 2 3 13 Feb 2019 Failure to ensure clinician competence for ultrasound examinations 2 2 17 May 2024 Failure to ensure coronial authority governs donation decisions 2 2 3 Jan 2024 Failure to ensure custody staff are suitable and competent to work with vulnerable people 2 7 3 Mar 2016 Failure to ensure door supervisors are licensed and competent for safety-critical work 2 4 2 May 2024 Failure to ensure effective paramedic clinical leadership and oversight 2 3 18 Feb 2021 Failure to ensure exercise commanders are competent in JSP539 safety requirements 2 1 1 Nov 2019 Failure to ensure mattresses are suitable for care recipients and beds 2 6 23 Jul 2019 Failure to ensure people wear reflective or high-visibility clothing 2 4 7 Sep 2016 Failure to ensure people with allergies have two adrenaline auto-injectors available 2 12 10 May 2019 Failure to ensure physical healthcare staff can safely care for patients with significant mental health needs 2 4 14 Nov 2017 Failure to ensure police officers consult infrequently used operational guidance 2 5 15 Dec 2022 Failure to ensure required surgical team coverage throughout operations 2 7 22 Jan 2024 Failure to ensure Scout leaders are competent for health and safety 2 8 22 Feb 2024 Failure to ensure timely Lead Practitioner appointment for mental health patients 2 1 15 Mar 2021 Failure to ensure timely required dental care for care-home residents 2 2 4 Nov 2022 Failure to escalate safety concerns after a high-risk patient leaves hospital 2 4 15 Oct 2025 Failure to establish and address patients’ ability to access advised emergency care 2 3 7 Apr 2025 Failure to implement the Patient Safety Incident Response Framework 2 3 28 Mar 2024 Failure to inform patients about clinicians’ qualifications and experience 2 13 17 Sep 2025 Failure to integrate complex health and social care needs 2 2 9 Oct 2023 Failure to investigate persistent or severe pain 2 3 6 Mar 2023