Safety concerns raised by coroners

Unreliable safety CCTV monitoring systems 23 47 3 Apr 2025 Failure of emergency alarm response 22 38 23 Mar 2026 Failure to ensure clear and followed instructions for safe equipment use 22 38 31 Mar 2026 Failure to provide timely clinically required blood tests 22 41 7 Feb 2026 Failure to supervise clinicians during clinical work 22 42 17 Dec 2025 Inadequate control of access to means of self-harm 22 26 20 Mar 2026 Insufficient multi-disciplinary coordination in mental health care 22 34 5 Feb 2026 Uncontrolled collision risks at hazardous road bends 22 30 26 Mar 2026 Unreliable coordination of mental health crisis responses 22 41 24 Mar 2026 Unreliable dual-diagnosis care pathways 22 36 30 Apr 2026 Unreliable implementation of medication changes 22 31 8 Feb 2026 Unreliable mental-health patient leave arrangements 22 36 1 Jun 2026 Unsafe reliance on agency staff for clinical staffing 22 31 8 Feb 2026 Failure to assess and respond promptly to significant signs of injury 21 44 26 Jun 2026 Failure to maintain required continuous patient observation 21 29 27 May 2026 Failure to maintain roads, pavements and verges in a safe state of repair 21 24 28 Aug 2024 Failure to provide face-to-face clinical assessment when clinically indicated 21 32 14 Jan 2026 Failure to provide timely clinical follow-up after medication prescribing 21 29 6 Jan 2026 Failure to reliably notify primary care of changes affecting patient care 21 35 15 Oct 2025 Inadequate warnings about location-specific hazards at public waterside locations 21 38 26 Feb 2026 Unreliable airway management during emergency care 21 37 31 Mar 2026 Unreliable availability and readiness of defibrillators for emergency response 21 40 8 May 2026 Unreliable care-coordinator provision and cover for mental health service users 21 27 18 May 2026 Unreliable Care Programme Approach care coordination 21 34 12 Jan 2026 Unreliable interim mental health support during care transitions 21 38 5 Sep 2025