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 summaryConcerns include prolonged waits for medical assessment and beds in the Emergency Department, alongside missed opportunities to recognise patient deterioration. Systemic issues in health and social care contribute to high ED demand, impeding timely monitoring and treatment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified insufficient national standard operating procedures for ambulance services to contact Distribution Network Operators (DNOs) regarding electrical hazards. This can delay life-saving treatment and pose safety risks for responders due to multiple DNOs and the absence of a single national emergency number.
Addressed to: Association of Ambulance Chief Executives; Energy Networks Association; Health and Safety Executive; NHS Digital; Ofgem
AI-generated concerns summaryThe coroner noted a lack of staff training in CPR and first aid, no emergency procedures or equipment, and no supervision in the dining room. Concerns also included the absence of post-hospital admission risk assessments and CQC action plan monitoring.
Addressed to: Health and Safety Executive; Hibiscus Housing Association Limited; Quality Care Commission; Wolverhampton City Council
AI-generated concerns summaryThe coroner raises concerns about insufficient recognition of the link between domestic abuse and suicide in policies, and inadequate systems to identify and care for vulnerable individuals not meeting high-risk criteria. There are also gaps in inter-agency information sharing and coordination for complex cases.
Addressed to: Department of Health and Social Care; Home Office; Ministry of Justice
AI-generated concerns summaryConcerns included the absence of appointment letters for mental health services at HMP Northumberland, discharge without in-person follow-up for missed appointments, and no weekend triage for kiosk referrals or urgent assistance warnings.
Addressed to: Tees, Esk and Wear Valley NHS
AI-generated concerns summaryThe coroner noted a lack of systems at Lambton House Care Home to ensure important information, such as a patient's fall, was conveyed to visiting healthcare professionals.
Addressed to: Lambton House LTD
AI-generated concerns summaryThe coroner noted delays in calling an ambulance, incomplete nursing notes, missing medication records, and a lack of documented oral cavity checks for the patient. Additionally, staff on duty demonstrated insufficient knowledge of the patient's condition.
Addressed to: Care Quality Commission; Corbett House Nursing Home; Worcestershire County Council
AI-generated concerns summaryThe care home lacked an effective exit control process or alert system to prevent vulnerable residents at high risk of falls from entering the garden unsupervised, and staff observation was hindered by other duties.
Addressed to: Westlands Care Home
AI-generated concerns summaryThe coroner noted that Mental Health Act admission criteria were not considered when sectioning was declined. A recommended face-to-face meeting after recent suicide attempts was replaced by a telephone call, hindering effective analysis before case closure.
Addressed to: LPFT Legal Services; NAViGO Grimsby
AI-generated concerns summaryThe coroner noted clinicians were unaware of a prior diagnosis, critical information was not shared with the patient and family on discharge regarding anticoagulant risks, and specialist advice on anticoagulation was not followed or documented.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in distributing ligature cutters to frontline officers, with only approximately 25% issued by October 2022. Concerns were also raised about the lack of specific training for response officers on handling situations involving suspended individuals.
Addressed to: South Wales Police
AI-generated concerns summaryThe coroner identified ongoing safety risks at Capital Karts due to inadequate track marshal checks for loose hair and clothing. Concerns were raised about a lack of improved training and monitoring for marshals, and management's commitment to addressing these deficiencies.
Addressed to: Capital Karts Trading Ltd
AI-generated concerns summaryThe coroner noted the A48 ‘Forage roundabout junction’ appears dangerous and requires changes to improve road user awareness and slow down approaching drivers to prevent further deaths.
Addressed to: Vale of Glamorgan Council
AI-generated concerns summaryThe coroner noted slow progress in reviewing and acting on intra-hospital transfers, particularly regarding the vascular pathway for emergency admissions. There are also concerns about the slow development and lack of enforcement of a pan-Local Health Board ambulance handover plan to improve resource availability.
Addressed to: Betsi Cadwaladr University Local Health Board; Welsh Ambulance Service Trust
AI-generated concerns summaryThe provided document extract contains boilerplate text regarding the duty to respond and general statements about preventing future deaths, but does not detail specific coroner's concerns.
Addressed to: HMPPS; HMP YOI Portland; NHS England; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an "obvious risk" related to prison rules, particularly concerning individuals identified as at chronic risk of suicide or self-harm. A national proposal has been made to address and remove this specific risk.
Addressed to: HMP Wakefield; Ministry of Justice
AI-generated concerns summaryThe coroner identified the absence of a care and treatment plan for specific needs, an issue not identified by a Serious Incident Investigation. Concerns also related to poor documentation of unescorted leave and delayed police alerts.
Addressed to: Central and North West London NHS Foundation Trust; Department of Health and Social Care; The Chief Coroner for England and Wales
AI-generated concerns summaryThe coroner noted that detailed assessments of vulnerable and elderly patients were conducted over the telephone, which led to incorrect information about the deceased's needs. The report suggests that assessments should be face-to-face and involve family members.
Addressed to: Central North West London NHS Foundation Trust; Milton Keynes Adult Social Care
AI-generated concerns summaryThe coroner raises concerns about the significant increase in children and young people seeking support for emotional well-being and mental health difficulties since the Coronavirus pandemic, leading to substantial delays in accessing treatment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted inadequate contact arrangements for a vulnerable person, as their personal advisor's phone was consistently off without a redirect, and the provided crisis number led only to an answerphone.
Addressed to: Kent County Council