Safety concerns raised by coroners

Unreliable transfer of NHS 111 information to emergency departments 2 3 13 Jun 2025 Unreliable transfer of triage information for urgent clinical appointments 2 3 6 Mar 2018 Unreliable triage in walk-in and minor-injury centres 2 7 10 Aug 2025 Unreliable triage of GP referrals across referral routes 2 4 30 Mar 2026 Unreliable university handling of student mental-health disclosures 2 5 28 Oct 2019 Unreliable urgent recall of discharged patients requiring hospital care 2 3 17 Jan 2018 Unreliable use of the WHO Surgical Safety Checklist 2 5 16 May 2016 Unreliable vascular surgery referral pathways 2 2 13 Mar 2024 Unreliable vehicle suspension safety controls 2 2 19 Mar 2019 Unreliable vehicle tyre safety controls 2 3 28 Apr 2015 Unreliable verification of clinicians’ competence before independent clinical practice 2 5 17 Sep 2025 Unreliable vulnerability assessment in emergency accommodation decisions 2 2 9 Mar 2026 Unreliable welfare-call arrangements when patients cannot receive calls 2 5 12 Oct 2015 Unreliable Welfare Officer contact arrangements 2 3 10 Mar 2021 Unreliable winter road maintenance response 2 1 21 Jul 2016 Unsafe agricultural bale handling and transport 2 3 17 Apr 2020 Unsafe allocation and competence of specialist sexual-offences investigators 2 4 6 Oct 2020 Unsafe assessment and management of facial fractures 2 2 8 Sep 2022 Unsafe breastfeeding arrangements exposing babies to suffocation risks 2 5 12 Dec 2024 Unsafe busway and adjacent-road design 2 4 1 Dec 2020 Unsafe clinical learning environments for trainee midwives 2 2 31 Dec 2021 Unsafe clinical management of hyponatraemia 2 8 12 Jun 2018 Unsafe close-range firearms operations 2 3 8 Jul 2025 Unsafe control of electrical systems in prison cells 2 3 17 Jan 2024 Unsafe delegation of clinical duties and decisions 2 2 4 Dec 2023