Browse 6,458 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
Contains public sector information licensed under the Open Government Licence v3.0.
AI-generated concerns summaryThe coroner noted the high toxicity of propranolol even at small doses, with no antidote, requiring GPs to be aware of overdose consequences, and recommended GPs enquire about gambling habits.
Addressed to: Royal College of General Practitioners
AI-generated concerns summaryThe coroner raised concerns about an unrecognised proximity risk to inspectors working beneath pressurised air suspension systems during visual inspections. Existing guidance did not address unexpected component failure during undisturbed inspections, and awareness of this risk was limited across the sector.
Addressed to: Driver and Vehicle Standard Agency; Health and Safety Executive; Society of Motor Manufacturers and Traders
AI-generated concerns summaryThe coroner raises concerns about a gap between ambulance response categories 1 and 2, where some patients require an immediate response due to risk to life but do not meet Category 1 criteria, especially if they are alone and unable to update their condition.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a lack of understanding regarding how controlling and coercive behaviour can negatively affect a person's decision-making ability. Concerns were raised that the Mental Capacity Act 2005, as currently drafted, does not fully recognise this impact.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of protocol for patients receiving both NHS and private psychiatric care, leading to uncommunicated medication changes and potential confusion. This raises a risk to patient safety as NHS services may not be aware of private treatment.
Addressed to: Northamptonshire Healthcare NHS Foundation Trust; Northamptonshire Integrated Care Board
AI-generated concerns summaryThe coroner raised concerns that the East of England Ambulance Services Trust's CAD system contained an inaccurate address and map database, specifically for a property that had been established for over 11 years.
Addressed to: Ordnance Survey
AI-generated concerns summaryThe coroner noted insufficient record-keeping regarding information provided about treatment services and identified potential for confusion in advice given to Mr Dickson, also questioning inter-service communication.
Addressed to: Recovery Steps
AI-generated concerns summaryThe coroner noted that Mr Dickson's supervision records were destroyed after his death and were not available for the inquest. Insufficient evidence was provided regarding the retention and non-destruction of records, as the trust's policy did not address this.
Addressed to: Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that information sharing procedures between CNTW and Recovery Steps were not adequate to ensure proper exchange of information about service users, irrespective of their treatment pathway status.
Addressed to: Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust; Recovery Steps Cumbria
AI-generated concerns summaryConcerns identified include limited awareness and follow-up of salbutamol overuse in asthma patients, and ambulance handover delays that reduced emergency response capacity. The report also notes unclear wording in NHS Pathways triage questions and risks associated with families transporting critically unwell patients when ambulances are unavailable.
Addressed to: Asthma & Lung; Care Quality Commission; Department of Health and Social Care; NHS England; NHS Pathways/ NHS Digital; Royal College for GP’s
AI-generated concerns summaryThe coroner noted that the Trust chose not to investigate Mrs Creegan's death under NHS England’s Patient Safety Framework, despite an inaccurate initial cause of death, a missed diagnosis of infective endocarditis, and insufficient monitoring of her heart failure during treatment.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns that 17-year-old drivers, shortly after passing their test, can drive unsupervised on any UK road, including motorways, potentially leading to further fatal collisions.
Addressed to: Department for Transport
AI-generated concerns summaryThe report highlights that sepsis signs were not appropriately recognised and the Sepsis 6 Pathway was not followed, with no early consultant review sought. Concerns were also raised regarding communication issues with consultants and a junior doctor feeling unable to challenge decisions or seek alternative opinions.
Addressed to: Colchester General Hospital; East Suffolk and North Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inconsistent provision of mobility aids, such as walking frames, for patients transferring between hospital wards, leading to delays in patients receiving previously allocated equipment.
Addressed to: York & Scarborough Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an ongoing insufficiency of mental health beds, posing a risk to life. This situation may lead to an elevated referral threshold, potentially denying beds to patients with a clinical need.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns were raised that a transthoracic echocardiogram result was not reviewed for several months, with no system in place to ensure timely clinician review of such results. There was also no pathway for the echocardiography team to flag critical findings.
Addressed to: North Middlesex university Hospital; Royal Free London NHS Foundation Trust
AI-generated concerns summaryCoroner notes that healthcare and prison staff lacked awareness of the food refusal policy, leading to gaps in timely mental capacity assessments, consideration of hospital transfer, and expedited medical evaluations. Furthermore, Next of Kin were not adequately informed about food/fluid refusal.
Addressed to: Government Legal Department; Midlands Partnership NHS Foundation Trust; Practice Plus Group
AI-generated concerns summaryThe coroner identified a lack of awareness among care home and sheltered housing providers, including Havebury Housing Partnership, regarding the UK Power Networks Priority Services Register, which offers additional support during power outages to vulnerable residents.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that information forwarded from NHS 111 to a GP practice was reviewed by non-medically qualified staff and not added to the patient's medical record, which could lead to missed information and inappropriate medical decisions.
Addressed to: Department of Health and Social Care; Royal College of General Practitioners
AI-generated concerns summaryThe coroner identified issues with the multi-disciplinary team's access to accurate patient information, a lack of accountability for planned drug tests, and insufficient documentation of leave decisions and care plans. Further concerns were raised about the quality of post-incident investigations.
Addressed to: Alternative Futures Group