Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summarySignificant and unacceptable delays in ambulance attendance have worsened over ten years, the coroner noted. There is also inadequate cohesive planning for both short-term pressures and long-term solutions to address these multifactorial delays.
Addressed to: Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust, North Wales Local Authorities
AI-generated concerns summaryThe coroner noted that University Hospitals of Birmingham NHS Foundation Trust is not adhering to its own guidance requiring obstetric consultants to be present at multiprofessional appointments for complex birth choices. The current fragmented approach, developed out of necessity, risks miscommunication and and deprives patients of hearing all professional perspectives …
Addressed to: University Hospitals of Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that staff shortages compromised safety, with current Band 2 and Band 3 staff complements being low and predicted to further reduce significantly.
Addressed to: HM Prison and Probation Services
AI-generated concerns summaryConcerns are raised that insufficient action has been taken to prevent people from jumping from a specific roof terrace, following two deaths from that location within eight weeks.
Addressed to: Landsec
AI-generated concerns summaryHerefordshire Council's communication process failed to contact the deceased, or approved contacts, prior to his death. His housing application was not progressed, preventing his vulnerability under the Housing Act 1996 from being established, and an effective system for identifying process failures was noted as needed.
Addressed to: Herefordshire Council
AI-generated concerns summaryThe coroner noted footwear was not removed during a prolonged emergency department stay, leading to a necrotic toe without appropriate management. Concerns were also raised about a lack of preventative pressure area care, delayed reassessment, and non-mandatory pressure care training within the Trust.
Addressed to: Wye Valley NHS Trust
AI-generated concerns summaryThe coroner notes that the potent illicit synthetic opiate RT4563 is not currently controlled under the Misuse of Drugs Act 1971, despite recommendations to classify it. This creates a high risk of fatal overdose, as users cannot know the actual contents of the illicit substance.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner noted the absence of a strategy for family engagement and 24-hour crisis support access for the patient, raising concerns that these key guidelines were not fully integrated into health board policy and practice.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryLengthy waiting lists for mental health therapy due to therapist shortages, and prosecuting authorities may not fully consider mental health vulnerability when making prosecution decisions. There is no clear national mechanism to share learning on these issues.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner noted the lack of a contingency plan and standard operating procedures for managing a full Intensive Care Unit, which meant a patient needing intensive care could not be admitted.
Addressed to: Barking, Havering and Redbridge University Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that Mental Health Liaison teams in acute hospital A&E departments cannot use Section 5 holding powers due to their employment by a separate Mental Health Trust, creating a risk of patients absconding before an acute hospital doctor can intervene.
Addressed to: Integrated Health Board NHS Sussex; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the Civil Aviation Authority's self-declaration system for pilots over 70, noting a lack of comprehensive medical guidance for pilots and professionals, and the absence of independent third-party assessment of fitness for some older pilots.
Addressed to: Department for Transport; UK Civil Aviation Authority
AI-generated concerns summaryThe coroner noted high patient volumes delayed the review of critical blood test results. Concerns were also raised about the lack of adherence to national guidance for consultant review of specific patient groups and a misunderstanding regarding the necessity of blood tests before a CT scan.
Addressed to: Department of Health and Social Care; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of escalation to senior medical staff concerning patient deterioration, inaccurate observations by an agency nurse without demonstrated competence or induction, and significant delays in urgent investigations and escalating care.
Addressed to: Spire Healthcare Limited
AI-generated concerns summaryThe coroner noted a series of incidents, including two fatalities, on a specific road stretch and raised concerns that no timescale had been set for an assessment of additional road markings to enhance safety.
Addressed to: Highways Department
AI-generated concerns summaryThe coroner identified issues with the EMIS patient record system, including the risk of ended repeat prescriptions being re-issued and the grouping of prescriptions by amount rather than issue date, which complicated accurate tracking. Staff also experienced challenges in interrogating the system for prescription history.
Addressed to: EMIS Health
AI-generated concerns summaryThe coroner noted that the ambulance service (SECAMBS) regularly operates at Stage 4 of its Surge Management Plan, indicating that demand significantly outstrips resources and calls are not responded to within target timeframes.
Addressed to: Department of Health and Social Care; South East Coast Ambulance Service
AI-generated concerns summaryThe coroner noted that SECAMBS frequently operates at Stage 4 of its Surge Management Plan, leading to demand for the service outstripping available resources and an inability to meet target response times.
Addressed to: Department of Health and Social Care; South East Coast Ambulance Service
AI-generated concerns summaryThe coroner noted insufficient consultant psychiatrist resource at HM Prison, Wakefield, with only one day per week for 750 prisoners with complex mental health needs. This raises concerns that other long-term inmates may not receive the specialist care they need, potentially increasing the risk of future deaths.
Addressed to: HM Prison Wakefield; Ministry of Justice; NHS England
AI-generated concerns summaryThe coroner noted a national shortage of acute psychiatric beds to treat patients requiring immediate inpatient assessment and care, a situation which has not improved.
Addressed to: Department of Health and Social Care; NHS England & NHS Improvement