Browse 6,470 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 raised concerns that Stefan, a young person with autism, did not have a case manager or key worker as recommended by NICE guidance. Current service provision for these roles is restricted to a small cohort, leaving many young people with autism without this support to navigate services.
Addressed to: NHS Kent and Medway Clinical Commissioning Group
AI-generated concerns summaryGP practice IT systems lack an automatic flag for patients who do not respond to National Screening Service smear test invitations, meaning GPs must manually add warnings. An automatic system could standardise care and increase patient safety.
Addressed to: Department of Health and Social Care; Egton Medical Information Systems Limited; NHS Digital; TPP Group Limited
AI-generated concerns summaryA chevron sign near a road bend was overgrown, and two of three road markers had been removed and not replaced. No remedial action was evident despite the relevant authority being notified.
Addressed to: Monmouthshire County Council
AI-generated concerns summaryThe coroner noted staffing pressures in Primary Mental Health Services resulting in assessment delays and long waiting lists for counselling. There was also a lack of structured interim support or monitoring for low-risk patients awaiting counselling, with services requiring self-referral.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified longstanding, multifactorial issues leading to delayed ambulance attendances, including handover delays between the Welsh Ambulance Service NHS Trust and the Health Board, which continue to pose a risk of future deaths.
Addressed to: Betsi Cadwaladr University Health Board, Welsh Ambulance NHS Trust
AI-generated concerns summaryHealthcare and mental healthcare staff at HMP Hewell did not sufficiently identify or reduce Andrew's suicide/self-harm risk, nor did they adequately share information. Concerns also noted the Duty Governor's insufficient enquiries regarding a health screen document.
Addressed to: Various
AI-generated concerns summaryThe coroner raised concerns about the lack of regulation for supported accommodation for 18-21 year olds, which means some providers lack adequate training and resources for complex needs. Additionally, there is no standard referral form for 16-25 year olds entering supported housing, which can lead to vital information being missed.
Addressed to: Department for Education; Department of Health and Social Care; London Borough of Ealing; London Borough of Islington; West London Alliance
AI-generated concerns summaryConcerns were raised regarding the use of weaker methods for securing pre-cast concrete panels on farms and a lack of understanding among farm workers and inspectors about optimal securing practices, posing a risk of collapse. There is also a risk of workers re-securing panels insecurely without professional guidance.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner raised concerns about inadequate glazing in double doors installed in the 1990s and their proximity to the bottom of stairs. A review across other Conservative Clubs was recommended to ensure compliance with current health and safety and fire regulations.
Addressed to: Association of Conservative Clubs LTD
AI-generated concerns summaryThe coroner noted that undertakings previously given by the trust regarding placenta retention processes, including storing placentas for 48 hours and implementing a new Standard Operating Procedure (SOP) with staff training, had not been completed.
Addressed to: Royal Berkshire NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a significant delay in implementing recommendations from an expert working group regarding Isotretinoin prescribing for patients under 18, despite ongoing reports of psychiatric adverse events.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that individuals released from police custody, often a distance from home, may lack money, communication means, or transport to return home, requesting a review of arrangements for their return.
Addressed to: Wiltshire Police
AI-generated concerns summaryAn inaccurate DBS certificate failed to record a past violent offence, which allowed Mr Roberts to be employed in a role with access to firearms. The coroner noted it was unclear whether the error originated with the DBS or the Metropolitan Police Service.
Addressed to: Disclosure and Barring Services, Metropolitan Police Services and Proof Master
AI-generated concerns summaryThe coroner noted a mismatch between the COMPACT risk assessment and the ACT stop priority for a missing person's vehicle, due to a lack of formal guidance, training, or protocols for correlating these two systems. This absence of guidance on how these critically important systems operate together safely appears to …
Addressed to: College of Policing; Home Office; Metropolitan Police Service; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner raised concerns that the non-functional lights on the pedestrian refuge on the B197 Digswell Hill, specifically the illuminated bollard and streetlamp, present a danger to road users and pedestrians.
Addressed to: Hertfordshire County Council; National Highways; UK Power Networks Holdings Ltd
AI-generated concerns summaryThe coroner identified a blurring of boundaries between the intended 1:1 therapeutic escorted leave for MHA patients and the practice of one staff member accompanying multiple patients to an unsecure car park for smoking breaks. This meant restricted leave was used for smoking, and consideration was not given to a …
Addressed to: South West London and St George’s Mental Health NHS Trust
AI-generated concerns summaryDelays in Emergency Department clinician reviews and CT scan reporting were identified due to staff shortages and high demand. The coroner also noted insufficient awareness and protocols in DGH settings for identifying 'silver trauma' cases, impacting timely transfer.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of national guidance for oesophageal stricture management and the absence of a commissioned specialist service in Greater Manchester. Communication within the regional Upper GI MDT was also affected by inconsistent trust representation and insufficient sharing of agreed patient actions.
Addressed to: Greater Manchester Integrated Care; NHS England
AI-generated concerns summaryThe coroner identified inconsistent IV fluid administration, including extended periods without fluids, and the absence of fluid balance charts contrary to Trust policy. Concerns were also raised about poorly maintained clinical records and inadequate consultant review of fluid monitoring during ward rounds.
Addressed to: Barking, Havering & Redbridge NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner notes that while UHL has implemented new policies for central venous catheter safety during patient mobilisation, there is concern that other NHS Trusts may not have similar preventative measures in place.
Addressed to: Department of Health and Social Care