Coroners in England and Wales sent 109 warnings to health bodies and the government in 2023 highlighting long NHS waits, staff shortages or a lack of NHS resources, the BBC has found.
The number of cases identified that were linked to NHS pressures was the highest in the past six years.
Prevention of future death reports (PFDs) are sent when a coroner thinks action is needed to protect lives.
About 35,000 inquests take place in England and Wales each year. In a fraction of those - about 450 - the coroner writes a PFD, or Regulation 28, report.
The BBC analysed 2,600 PFDs - and supporting documentation - sent between 2018 and 2023.
The proportion of the total number of PFD reports that referenced an NHS resource issue rose to one in five in 2023, from one in nine in the two years before Covid.
Of the 540 reports written last year, 109 were found that highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners.
Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services.
The government says it "responds to, and learns from, every report".
Source: BBC News, 8 March 2024
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