Department of Health and Social Care
- Insufficient social care provision leading to discharge delays
Department of Health and Social Care · National body
8 reports · 3 coroners · 2020–2026Closely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coroners · 2025–2026Closely relatedConfidence 0.90 · highNo published response to an earlier report
- 55 reports · 32 coroners · 2015–2026Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Overcrowded emergency department increases patient mortality
Department of Health and Social Care · National body
5 reports · 4 coroners · 2020–2026Closely relatedConfidence 0.87 · high - Lack of verbal warning and fire risk flag for paraffin emollient creams
Department of Health and Social Care · National body
3 reports · 3 coroners · 2017–2026Closely relatedConfidence 0.85 · high - Ambulance crew waiting in corridor due to insufficient clinical space
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2026Closely relatedConfidence 0.90 · high - Lack of regular first aid training among custodial staff
Department of Health and Social Care · National body
2 reports · 2 coroners · 2025–2026Closely relatedConfidence 0.90 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coroners · 2020–2026Closely relatedConfidence 0.90 · high - Maternal heart rate misinterpreted as fetal heart rate
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2026Closely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coroners · 2015–2026Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Insufficient inpatient bed capacity leading to delayed discharges and patient harm
Department of Health and Social Care · National body
26 reports · 15 coroners · 2015–2026Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - Medically fit patients occupying hospital beds leading to ED overcrowding
Department of Health and Social Care · National body
3 reports · 2 coroners · 2023–2026Identical hazardConfidence 0.90 · high - Delayed discharge increases infection risk for frail elderly patients
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2026Closely relatedConfidence 0.90 · high - 2 reports · 2 coroners · 2020–2026Identical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of electronic access to primary care medical notes
Department of Health and Social Care · National body
3 reports · 3 coroners · 2014–2026Identical hazardConfidence 0.90 · high - Sustained high operational pressure at REAP Level 4
Department of Health and Social Care · National body
2 reports · 2 coroners · 2024–2026Identical hazardConfidence 0.90 · high - Inappropriate prison environment for mental health treatment
Department of Health and Social Care · National body
2 reports · 2 coroners · 2018–2025Closely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coroners · 2023–2025Closely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of specialised personality disorder services
Department of Health and Social Care · National body
2 reports · 2 coroners · 2021–2025Closely relatedConfidence 0.80 · moderate - 4 reports · 1 coroner · 2024–2025Closely relatedConfidence 0.90 · high
- Inadequate transition pathway from CAMHS to adult services
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2025Closely relatedConfidence 0.90 · high - 3 reports · 2 coroners · 2020–2025Identical hazardConfidence 0.90 · high
- 2 reports · 2 coroners · 2021–2025Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Locum registrar without assessment or supervision
Department of Health and Social Care · National body
2 reports · 2 coroners · 2020–2025Closely relatedConfidence 0.70 · moderate - Misinterpretation of centile chart guidance leading to delayed recognition of fe
Department of Health and Social Care · National body
2 reports · 1 coroner · 2021–2025Closely relatedConfidence 0.80 · moderate - Absence of learning disability liaison nurse support
Department of Health and Social Care · National body
2 reports · 2 coroners · 2019–2025Identical hazardConfidence 0.92 · high - Inadequate incident reporting and review systems
Department of Health and Social Care · National body
2 reports · 1 coroner · 2024–2025Closely relatedConfidence 0.90 · high - 2 reports · 2 coroners · 2024–2025Closely relatedConfidence 0.90 · high
- Lack of staff training in cardiac arrest recognition and first aid
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2025Closely relatedConfidence 0.90 · high - Delayed emergency department treatment due to overcrowding
Department of Health and Social Care · National body
2 reports · 1 coroner · 2023–2025Identical hazardConfidence 0.90 · high - Inconsistent iv fluid administration and inadequate shock management
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2025Closely relatedConfidence 0.86 · high - 3 reports · 3 coroners · 2021–2025Identical hazardConfidence 0.90 · high
- 2 reports · 2 coroners · 2024–2025Closely relatedConfidence 0.90 · high
- Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coroners · 2018–2025Identical hazardConfidence 0.95 · high - Insufficient ambulance availability leading to delayed response
Department of Health and Social Care · National body
7 reports · 7 coroners · 2016–2025Closely relatedConfidence 0.85 · highNo published response to an earlier report - Patients not informed of surgical risks in Turkey
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2025Identical hazardConfidence 0.90 · high - Lack of information sharing between online prescribing services and GP systems
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2025Closely relatedConfidence 0.90 · high - Incompatible IT systems block cross provider record access
Department of Health and Social Care · National body
7 reports · 5 coroners · 2018–2025Closely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coroners · 2023–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report
- Theatre capacity shortage leading to delayed procedures
Department of Health and Social Care · National body
3 reports · 3 coroners · 2022–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Inadequate clinical documentation of patient condition and decisions
Department of Health and Social Care · National body
2 reports · 2 coroners · 2020–2024Closely relatedConfidence 0.90 · high - 2 reports · 2 coroners · 2017–2024Closely relatedConfidence 0.90 · high
- Lack of regular allergy review and named accountability for allergy services
Department of Health and Social Care · National body
3 reports · 3 coroners · 2023–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Misleading packaging resembling sweets leading to ingestion
Department of Health and Social Care · National body
2 reports · 2 coroners · 2013–2024Closely relatedConfidence 0.90 · highNo published response to an earlier report - Unrestricted online purchase of lethal prescription medication
Department of Health and Social Care · National body
5 reports · 5 coroners · 2014–2024Identical hazardConfidence 0.90 · highNo published response to an earlier report - 3 reports · 3 coroners · 2021–2024Identical hazardConfidence 0.90 · highNo published response to an earlier report
- Critical clinical information lost during verbal handover
Department of Health and Social Care · National body
2 reports · 2 coroners · 2015–2024Closely relatedConfidence 0.85 · high - Lack of personal care and health deterioration in domiciliary care
Department of Health and Social Care · National body
2 reports · 1 coroner · 2023–2024Closely relatedConfidence 0.85 · high - Inconsistent sharing of medical notes between agencies
Department of Health and Social Care · National body
2 reports · 2 coroners · 2019–2024Identical hazardConfidence 0.90 · highNo published response to an earlier report - Inadequate clinical records hinder investigations
Department of Health and Social Care · National body
3 reports · 1 coroner · 2023–2024Identical hazardConfidence 0.90 · high - Window restrictors fail to prevent opening beyond 100mm
Department of Health and Social Care · National body
2 reports · 2 coroners · 2015–2024Identical hazardConfidence 0.90 · high - Delayed mental health bed allocation leading to patient deterioration
Department of Health and Social Care · National body
2 reports · 2 coroners · 2013–2024Identical hazardConfidence 0.90 · high - Insufficient probation officer staffing creates safety risks
Department of Health and Social Care · National body
2 reports · 2 coroners · 2019–2024Closely relatedConfidence 0.85 · highNo published response to an earlier report - Lack of residential substance misuse treatment for under 18
Department of Health and Social Care · National body
2 reports · 2 coroners · 2023–2024Identical hazardConfidence 0.95 · high - 2 reports · 2 coroners · 2021–2024Identical hazardConfidence 0.90 · highNo published response to an earlier report
- 6 reports · 5 coroners · 2014–2024Closely relatedConfidence 0.80 · moderateNo published response to an earlier report
- Overcrowded emergency department leading to delays
Department of Health and Social Care · National body
3 reports · 3 coroners · 2020–2023Closely relatedConfidence 0.85 · high - 2 reports · 2 coroners · 2016–2023Closely relatedConfidence 0.90 · high
- Delay in reporting original x-ray findings to clinicians
Department of Health and Social Care · National body
2 reports · 2 coroners · 2015–2023Identical hazardConfidence 0.90 · high - 2 reports · 2 coroners · 2022–2023Closely relatedConfidence 0.90 · high
- 2 reports · 2 coroners · 2021–2023Identical hazardConfidence 0.90 · high
- Incompatible electronic records between mental and physical health services
Department of Health and Social Care · National body
2 reports · 1 coroner · 2021–2023Identical hazardConfidence 0.90 · high - Ambulance delays for frail elderly hip fracture patients
Department of Health and Social Care · National body
3 reports · 1 coroner · 2022–2023Closely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of action on high clozapine blood test results
Department of Health and Social Care · National body
2 reports · 1 coroner · 2020–2023Closely relatedConfidence 0.90 · high - Lack of timely reporting and registration of food allergy fatalities
Department of Health and Social Care · National body
2 reports · 2 coroners · 2020–2023Identical hazardConfidence 0.90 · high - 2 reports · 2 coroners · 2019–2023Closely relatedConfidence 0.80 · moderate
- 2 reports · 2 coroners · 2019–2023Identical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of coordinated support for vulnerable adults with complex needs
Department of Health and Social Care · National body
2 reports · 2 coroners · 2022–2023Closely relatedConfidence 0.85 · high - Shortage of emergency department consultants and middle-grade doctors
Department of Health and Social Care · National body
2 reports · 1 coroner · 2021–2023Closely relatedConfidence 0.90 · highNo published response to an earlier report - 2 reports · 2 coroners · 2022–2023Identical hazardConfidence 0.90 · high
- Insufficient mental health resources for children and young people
Department of Health and Social Care · National body
4 reports · 4 coroners · 2018–2022Closely relatedConfidence 0.85 · high - Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coroners · 2017–2022Identical hazardConfidence 0.90 · high - 2 reports · 2 coroners · 2018–2022Closely relatedConfidence 0.90 · highNo published response to an earlier report
- Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care · National body
4 reports · 3 coroners · 2013–2022Closely relatedConfidence 0.90 · highNo published response to an earlier report - Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care · National body
3 reports · 3 coroners · 2017–2022Closely relatedConfidence 0.90 · high - Absence of cardiotocography monitoring in maternity settings
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2021Closely relatedConfidence 0.80 · moderate - 2 reports · 2 coroners · 2013–2021Closely relatedConfidence 0.86 · high
- 2 reports · 2 coroners · 2019–2021Identical hazardConfidence 0.95 · highNo published response to an earlier report
- 2 reports · 2 coroners · 2017–2021Closely relatedConfidence 0.80 · moderate
- Inadequate staff knowledge of pressure sore prevention and equipment use
Department of Health and Social Care · National body
2 reports · 2 coroners · 2015–2021Closely relatedConfidence 0.85 · high - Insufficient family involvement in mental health care processes
Department of Health and Social Care · National body
2 reports · 2 coroners · 2019–2021Closely relatedConfidence 0.90 · highNo published response to an earlier report - Inadequate inter-agency communication about risk and urgency
Department of Health and Social Care · National body
2 reports · 2 coroners · 2015–2021Identical hazardConfidence 0.90 · high - Lack of public access to adrenaline auto-injectors
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2020Closely relatedConfidence 0.90 · high - Lack of joint access to NHS records by out of hours services
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2020Identical hazardConfidence 0.90 · high - Misunderstanding of section 135 mental health act powers leading to delays
Department of Health and Social Care · National body
2 reports · 2 coroners · 2019–2020Closely relatedConfidence 0.80 · moderate - Inconsistent mental health service provision for 16-18 year olds
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2019Closely relatedConfidence 0.80 · moderate - Simultaneous ambulance crew meal breaks reduce vehicle availability
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2019Closely relatedConfidence 0.80 · moderate - 2 reports · 2 coroners · 2016–2019Identical hazardConfidence 0.90 · high
- Inadequate allergy action plan communication in school
Department of Health and Social Care · National body
2 reports · 2 coroners · 2017–2019Closely relatedConfidence 0.88 · high - Missed breech presentation due to lack of routine prenatal scanning
Department of Health and Social Care · National body
2 reports · 2 coroners · 2013–2018Identical hazardConfidence 0.92 · highNo published response to an earlier report - Button battery ingestion risk in children's environments
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2018Identical hazardConfidence 0.90 · high - Lack of access to qualified psychologist during home treatment team care
Department of Health and Social Care · National body
2 reports · 1 coroner · 2014–2017Identical hazardConfidence 0.95 · highNo published response to an earlier report - Young people placed in adult mental health facilities
Department of Health and Social Care · National body
2 reports · 2 coroners · 2016–2017Closely relatedConfidence 0.85 · highNo published response to an earlier report - Inaccurate early warning score calculation by clinical staff
Department of Health and Social Care · National body
2 reports · 2 coroners · 2013–2017Closely relatedConfidence 0.80 · moderate - 2 reports · 2 coroners · 2014–2017Closely relatedConfidence 0.85 · high
- Chest drain insertion without pre-procedure checks
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2016Closely relatedConfidence 0.80 · moderate - Lack of antenatal screening for group B streptococcus
Department of Health and Social Care · National body
2 reports · 1 coroner · 2015–2016Identical hazardConfidence 0.95 · high - 2 reports · 2 coroners · 2013–2015Identical hazardConfidence 0.90 · highNo published response to an earlier report
- Repeated catheterisation without oversight or documentation
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2015Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - Unavailability of isoprenaline for heart transplant resuscitation
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2014Closely relatedConfidence 0.90 · high - Lack of interpreter framework in healthcare settings
Department of Health and Social Care · National body
2 reports · 1 coroner · 2014–2014Closely relatedConfidence 0.90 · high - Inappropriate use of intrapartum CTG guidance for antenatal monitoring
Department of Health and Social Care · National body
2 reports · 2 coroners · 2014–2014Closely relatedConfidence 0.80 · moderateNo published response to an earlier report - Communication breakdown between junior doctor and consultant
Department of Health and Social Care · National body
2 reports · 2 coroners · 2013–2014Closely relatedConfidence 0.90 · highNo published response to an earlier report