Safety concerns raised by coroners

Failure to conduct timely, appropriate clinical assessments 25 37 17 Feb 2026 Inadequate coordination between hospitals during patient care 25 41 24 Oct 2025 Inadequate road sight distance for drivers to identify hazards safely 25 26 23 Apr 2025 Unsafe anticoagulant management 25 40 28 May 2026 Unsafe implementation of choking-risk prevention measures 25 39 19 Feb 2026 Failure to control ligature risks in inpatient and custodial environments 24 32 20 Mar 2026 Failure to ensure timely transfer to an appropriate hospital care environment 24 42 24 Jun 2026 Failure to provide timely medical review of admitted patients 24 36 17 Jun 2025 Failure to provide timely urgent diagnostic investigations 24 36 18 Dec 2025 Failure to reliably disseminate contextualised safety learning to relevant staff 24 36 6 Feb 2026 Inadequate controls on access to online suicide-promoting content 24 19 29 Apr 2026 Inadequate driver licensing controls for road safety 24 15 1 Apr 2026 Inadequate multi-agency safeguarding coordination 24 60 5 Mar 2026 Inadequate prison reception safeguards 24 26 9 Feb 2026 Ineffective controls preventing access to railway tracks 24 19 4 Mar 2024 Unreliable assessment of patients’ mental state 24 46 17 Mar 2026 Unreliable doctor-to-doctor coordination of prescribing 24 36 21 Apr 2026 Failure to conduct required welfare checks on people in distress 23 37 4 Feb 2026 Failure to maintain follow-up of patients who disengage from care 23 38 1 Oct 2025 Failure to perform clinically indicated physical examinations 23 46 6 Mar 2026 Inadequate control of illicit substance use and supply in secure institutions 23 32 24 Mar 2026 Inadequate specialist placement arrangements for people requiring specialist care 23 26 7 May 2026 Inadequate visibility for road users at hazardous junctions 23 28 9 Apr 2025 Unreliable communication of critical medication information to GPs 23 41 19 Mar 2026 Unreliable interagency sharing of safeguarding risk information 23 43 3 Sep 2025