Table 1. Concerns raised by coroners, grouped by five higher-order themes, and how often they were reported
Theme (% of concerns)ConcernCases, n (%)
Failure to follow protocols (36)Failure or delay in appropriate assessments19 (17)
Failure to monitor treatment15 (13)
Omission of necessary treatment13 (12)
Delayed treatment12 (11)
Failure to review medicines11 (10)
Failure to take a history or see the patient10 (9)
Failure or delay in performing necessary scans8 (7)
Failure to triage patients appropriately7 (6)
Failure to follow recommended practices6 (5)
Failure to follow a protocol6 (5)
Failure to review medical records4 (4)
Failure to implement national guidelines3 (3)
Administration of drug in error1 (1)
Failure to arrange supervision1 (1)
Inability to care for both a patient’s physical and mental health1 (1)
Management of medication for care home residents1 (1)
Medication administered despite known allergy1 (1)
Communication (22)Poor communication28 (25)
Failure to keep accurate medical records28 (25)
Failure to escalate deterioration in patient to the relevant medical professionals5 (4)
Failure to seek specialist advice when indicated4 (4)
Failure to follow the advice of a senior clinician2 (2)
Failure to warn of the consequences of not taking medication2 (2)
Failure to inform the patient about a medical procedure and aftercare2 (2)
Failure to warn of adverse drug reactions1 (1)
Failure to obtain informed consent1 (1)
Safety (21)Poor systems35 (31)
Discharge process16 (14)
Non-robust investigation following the death15 (13)
Safety of facilities2 (2)
Nature of inspections of care homes1 (1)
Failure to address measures identified in risk assessment1 (1)
Failure to make a reasonable effort to ensure patient adherence1 (1)
Education and training (14)Inadequate training12 (11)
Inappropriate dosage for the patient9 (8)
Failure to appreciate the risk (of giving or not giving a drug)6 (5)
Lack of clinical knowledge5 (4)
Poor clinical decision making5 (4)
Poor awareness of symptoms4 (4)
Poor awareness of rare ADRs2 (2)
Poor awareness of rare complications of medical procedures1 (1)
Failure of training1 (1)
Drug awareness1 (1)
Poor awareness of drug—drug interactions1 (1)
Wrong method of administration1 (1)
Resources (7)Absence of national guidelines10 (9)
Understaffing7 (6)
Shortage or lack of availability of appropriate medical equipment3 (3)
Hospital opening times or availability2 (2)
Unavailable drug1 (1)
Inability to deliver care1 (1)
  • ADR = adverse drug reaction.