Safety concerns raised by coroners

Unreliable cross-Trust transfer arrangements for complex patients 2 3 6 May 2026 Unreliable daily logs for multidisciplinary prisoner safety information 2 3 27 Apr 2023 Unreliable death notification and verification records 2 8 5 May 2021 Unreliable decisions to start, stop or abandon racing 2 4 29 Sep 2023 Unreliable detection and reporting of clinically significant genetic variants 2 6 17 Oct 2023 Unreliable disclosure of confidential medical information to police for safety purposes 2 7 10 Nov 2020 Unreliable documentation and authentication of ECG review 2 4 30 May 2017 Unreliable emergency response arrangements at railway stations 2 7 23 Jun 2022 Unreliable emergency-response arrangements for bus and coach drivers 2 5 2 Aug 2022 Unreliable escalation of patient telephone referrals to GPs 2 7 11 Mar 2024 Unreliable exhaled carbon dioxide monitoring for neonates 2 6 28 Jun 2016 Unreliable fire-response instructions for residents 2 2 16 Jun 2021 Unreliable forensic collision investigations in fatal incidents 2 2 25 Jun 2025 Unreliable fulfilment of hospital-issued medication prescriptions 2 6 21 May 2026 Unreliable fundal-height measurement and recording 2 5 24 Jul 2019 Unreliable gas safety inspection arrangements 2 14 17 Jan 2020 Unreliable Gateway referral and assessment process 2 2 4 Oct 2019 Unreliable GMP computer system for safety-critical information 2 8 15 Apr 2016 Unreliable governance and public understanding of Physician Associate practice 2 11 24 Feb 2025 Unreliable handling of external clinical correspondence in prisons 2 3 4 Dec 2019 Unreliable handling of healthcare information-disclosure constraints in emergency call advice 2 3 1 Dec 2025 Unreliable handling of safeguarding allegations 2 5 3 May 2022 Unreliable handover of patients undergoing drug detoxification 2 3 21 Jan 2019 Unreliable Haven at Millview service arrangements 2 3 27 Apr 2026 Unreliable hospital bed bureau systems for identifying available beds 2 4 7 Aug 2015