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 identified confusion among multiple agencies regarding the funding, assessment, and provision of Matthew's care. This stemmed from differing understandings of care terms, leading to discrepancies between expected and actual care.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified delays in allocating Mr Largin to a neighbourhood team and the crisis team's failure to reassess him despite new information. There were also unrecorded decisions and insufficient clarity and shared understanding between teams on patient pathways and response times.
Addressed to: East London Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient ambulance service resources in Milton Keynes, which led to significant delays in dispatch and attendance for a patient, even after their incident category was upgraded.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of clear process for prisoners to consent to the disclosure of medical information about chronic conditions to front-line officers, leading to insufficient monitoring and awareness of how to respond to sudden medical episodes.
Addressed to: HM Prison and Probation Service, HMP Rochester and OXLEAS NHS Foundation Trust
AI-generated concerns summaryConcerns included excessive freeplay in Bendpak 2-post vehicle lifts, risking lifting pad displacement, and inadequate warnings for certain lift points. The coroner also noted issues with the recall and replacement of substandard gear ring bolts.
Addressed to: Bendpak Inc; International Organization of Motor Vehicle manufacturers; Liftmaster Ltd; Liftmaster Servicing; Precision Bodyshop Ltd; British Standards Institution; European Automobile Manufacturers’ Association; Volvo Car Corporation
AI-generated concerns summaryThe coroner raised concerns about the arrangements for public footpaths traversing fields with cattle, particularly cows with calves, citing an unacceptable risk of trampling incidents. Further clarity is needed regarding rules for walkers with dogs on public rights of way.
Addressed to: Department for Environment, Food and Rural Affairs; Health and Safety Executive; J A Mitchell & Sons; Wakefield Council
AI-generated concerns summaryMs Ayuk was not assessed for venous thromboembolism risk, contravening trust policy, and instructions to monitor her food and fluid intake were not adequately followed.
Addressed to: Department of Health and Social Care; East London Foundation Trust
AI-generated concerns summaryThe informal structure of the National Association of Police Fleet Managers may not robustly disseminate safety-critical information to all forces. Furthermore, there is no formal policy to prevent faulty police vehicles from being auctioned to the public, and no national standards for police garages.
Addressed to: National Police Chiefs Council
AI-generated concerns summaryThe coroner noted persistent issues with ambulance response times for Amber 1 patients, and a lack of improvement. Resources are allocated chronologically without considering clinical need, while interventions to expedite urgent cases are ad hoc and lack formal policy.
Addressed to: Department of Health and Social Care; Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted the absence of questions on reception health screens regarding family history of sudden cardiac death. Adding this to screening templates could help identify predispositions and prevent similar deaths.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified ongoing issues with Emergency Department overcrowding, stemming from a lack of community beds for medically fit patients. This results in significant delays for ambulance transfers and impacts emergency response times for the community.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of interoperability between Dorset Council Adult Social Care's Mosaic system and NHS SystemOne, limiting Adult Social Care's access to crucial patient medication information and review dates.
Addressed to: Dorset Clinical Commissioning Group; Dorset Council
AI-generated concerns summaryThe coroner identified serious failures in the management and monitoring of the South Base Armoury access system, which repeatedly malfunctioned and permitted incorrect single access to an officer. The override key PIN being common knowledge also enabled potentially unfettered access.
Addressed to: Bedfordshire Police Chief Constable and His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services
AI-generated concerns summaryThe death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of mental health support and intervention.
Addressed to: Department for Culture, Media and Sport; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the failure to exclude bilateral tension pneumothoraces during cardiac arrest and delayed recognition of surgical emphysema. There were also gaps in the anaesthetic department's post-death investigation and the Trust's system for triggering death investigations.
Addressed to: Care Quality Commission; Health Education England; NHS England; St Richards Hospital; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about limited public awareness regarding the risk of stroke from cocaine use and the variable availability of thrombectomy services across different geographical locations and times.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryInsufficient inpatient mental health beds and safe spaces meant patients awaited specialist care in emergency departments. The coroner also noted West Midlands Police's understanding of missing person classification and risk assessment.
Addressed to: Birmingham and Solihull Integrated Care Board; Birmingham and Solihull Mental Health NHS Foundation Trust; Department of Health and Social Care; University Hospital Birmingham NHS Foundation Trust; West Midlands Police
AI-generated concerns summaryThe coroner noted a significant delay in the individual receiving Cognitive Behavioural Therapy after hospital discharge. There were also concerns regarding inadequate community follow-up, with limited contact attempts by the Community Psychiatric Nurse and no physical sighting of the individual prior to her death.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe report highlights insufficient familiarity among doctors with Royal College guidance for patients returning to the emergency department, alongside a lack of clear processes for embedding critical learning points and assessing the understanding of new and senior staff.
Addressed to: George Eilot Hospital NHS Trust
AI-generated concerns summaryThe coroner raised concerns about a nearside cycle lane's design, which created a dilemma for cyclists going straight at a junction with right-turning vehicles, increasing blind spot risks. The lane's width of 0.95 metres was also noted to be less than recommended.
Addressed to: Department for Transport; Oxfordshire County Council