Safety concerns raised by coroners

Unreliable reporting of detainee safety concerns to responsible oversight functions 2 3 6 Jul 2020 Unreliable reporting of heat-illness cases 2 1 1 Nov 2019 Unreliable response to falls-detection alarms 2 3 23 Oct 2018 Unreliable response to Spice-related incidents in prisons 2 4 15 Dec 2025 Unreliable response to suicidal communications by text 2 5 8 Aug 2025 Unreliable Rule 35 reporting for vulnerable detainees 2 3 25 Oct 2024 Unreliable Safe and Well Visit risk-assessment and review processes 2 4 23 Nov 2023 Unreliable safeguards when patients leave before clinical assessment 2 5 8 Nov 2024 Unreliable safe-return arrangements after police custody release 2 13 8 Jun 2023 Unreliable safety arrangements for organised water-sports events 2 4 10 Apr 2025 Unreliable safety audits of holiday and rented accommodation 2 8 26 Jul 2022 Unreliable safety controls for vehicle repairs and maintenance 2 4 26 Sep 2025 Unreliable safety decisions to approve or change offender licence conditions 2 11 29 Nov 2022 Unreliable safety governance of spontaneous police pursuits 2 4 25 Jun 2025 Unreliable safety planning for organised dance music events 2 3 18 Jul 2018 Unreliable Saturday mental health assessment service for magistrates' court defendants 2 3 21 Oct 2025 Unreliable Section 17 support and discharge-planning arrangements for children in need 2 4 3 Oct 2016 Unreliable shared terminology for mental-health emergency responses 2 6 12 Jun 2023 Unreliable shared understanding of funded care and staffing requirements 2 2 6 May 2024 Unreliable staffing cover during care-staff breaks 2 3 14 Jan 2020 Unreliable strip-search arrangements in custody 2 4 24 May 2018 Unreliable supervisory review of mental-health clinical decisions 2 2 14 Mar 2023 Unreliable surgical counting controls 2 3 1 Jun 2015 Unreliable tracking and routing of electronic patient contacts in GP practices 2 3 15 Oct 2024 Unreliable transfer arrangements for at-risk mental health patients 2 5 25 Aug 2022