Safety concerns raised by coroners

Unreliable timeliness of radiology imaging and reporting 29 34 4 Mar 2026 Unsafe coordination of shared care 29 47 15 Jun 2026 Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries 28 34 26 Jun 2026 Failure to establish effective plans to address identified safety concerns 28 36 6 Jan 2026 Failure to provide timely suitable onward care placements for patients ready for hospital discharge 28 23 18 Jun 2026 Failure to recognise and respond to deteriorating mental health in service users 28 47 25 Jun 2026 Failure to update risk assessments after material changes or safety events 28 46 1 Jun 2026 Inadequate recording of medication prescribing decisions 28 36 27 Oct 2025 Insufficient emergency-department capacity for timely patient care 28 30 18 Jun 2026 Unreliable gathering and use of collateral information in mental health assessments 28 42 11 May 2026 Unreliable monitoring and follow-up of clinically required laboratory tests 28 47 8 Jun 2026 Unreliable welfare-check processes for people whose health is of concern 28 41 10 Jun 2026 Failure to reliably respond to patient breathing emergencies 27 62 16 Apr 2026 Inadequate competence assurance and induction for agency staff 27 35 19 Feb 2026 Inadequate thromboprophylaxis for patients at risk of venous thromboembolism 27 23 4 Jun 2024 Unreliable admission assessment of patients 27 35 27 May 2026 Unreliable documentation of safety risk assessments 27 27 12 Jan 2026 Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs 26 33 3 Jun 2026 Failure to carry out required neurological observations 26 36 12 Jun 2026 Failure to ensure safe prisoner transfers 26 39 9 Feb 2026 Failure to involve families and carers in mental health care planning and decisions 26 34 2 May 2026 Failure to provide timely access to clinically indicated CT scanning 26 26 17 Feb 2025 Unreliable objective criteria for safety risk assessment 26 45 7 Apr 2026 Unreliable root cause analysis processes 26 37 14 May 2024 Unsafe coordination and continuity during mental health service transfers 26 48 6 May 2026