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 summaryBarts Health Trust did not investigate Mr Ioannou’s death under the NHS England Patient Safety Framework, missing an opportunity to understand the infection's origin and address communication failures for a patient with a profound learning disability.
Addressed to: Barts Health NHS Trust; Department of Health and Social Care
AI-generated concerns summaryPatients discharged from psychiatric hospital in North Devon receive insufficient timely and effective housing support, as the accommodation assessment process does not adequately weigh the vulnerability of those with psychiatric illness. This raises the risk of mental health deterioration.
Addressed to: North Devon Council
AI-generated concerns summaryConcerns relate to the inability of a GP to promptly communicate with the Medical Assessment Unit or Accident and Emergency department regarding patient admissions. Internal hospital staff also experienced difficulty contacting the Medical Assessment Unit.
Addressed to: East Suffolk & North Essex NHS Trust
AI-generated concerns summaryDespite clear 'nil by mouth' instructions, multiple nursing staff repeatedly provided a patient with water, and routine tick-box record-keeping practices led staff to overlook crucial information. The coroner suggested this may indicate underlying attitudinal issues beyond policy.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe initial assessment by District Nurses did not record Mr. Blackman's next of kin details or a plan for gaining access. The no-access policy also lacked provision for police involvement when a patient's life might be at risk.
Addressed to: Central London Community Healthcare NHS Trust
AI-generated concerns summaryA breach in a stone wall near County Bridge, Barnard Castle, provides unrestricted and unguarded access from a public area to a 9-metre vertical drop onto rocks and the River Tees.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted a lack of guidance for physiologists on when pacemaker data should trigger cardiology review, limited knowledge of infective endocarditis, and inconsistent clinical information gathering and documentation practices within the Cardiac Device Clinic.
Addressed to: Cardiff and Vale University Health Board
AI-generated concerns summaryThe coroner noted insufficient communication and coordination between private ADHD clinics and NHS GPs, which can lead to duplicate prescriptions and patient confusion during transfers of care. This poses a risk for safe and continuous patient management.
Addressed to: NHS England
AI-generated concerns summaryCoroner identified insufficient safeguarding training and risk assessment concerning adult child to parent domestic abuse. There were also concerns about ineffective and non-immediate operational communication between mental health services and police for dual risk cases.
Addressed to: East London Foundation Trust; Metroplolis; North East London Foundation Trust
AI-generated concerns summaryThe coroner noted that the methadone prescribing agency was unaware of an opiate overdose and hospital admission, preventing a review of prescribing practices to mitigate future risks. This information gap could lead to future deaths.
Addressed to: Great Western Hospital
AI-generated concerns summaryMethods for assessing and interpreting pavement defect height may not accurately reflect the full extent of defects, potentially leading to them not being identified and preventative action not being taken.
Addressed to: Newport City Council – Highways
AI-generated concerns summary15-minute observation checks were not recorded contemporaneously, lacked a clear definition, and a special cell for vulnerable prisoners was in disrepair, providing access to ligature material that daily checks missed.
Addressed to: HMP Pentonville; HMPPS; Ministry for Justice
AI-generated concerns summaryThe coroner noted that an unchanged form and process for its handling could lead to a recurrence of errors. The report also highlights that a form intended for financial decisions contained an allergy section whose purpose was unclear, resulting in incorrect clinical information and suboptimal patient care.
Addressed to: NHS North East and North Cumbria Integrated Care Board
AI-generated concerns summaryThe coroner noted that general practices in South Trafford cannot directly refer urgent, high-risk patients to the Home Based Treatment Team (HBTT), leading to delays through the CMHT, especially over weekends. This differs from other boroughs within the same trust.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of national guidelines for assessing paediatric heart conditions like myocarditis in A&E, delayed radiologist reporting of chest X-rays, and incomplete documentation of observations and medical handovers.
Addressed to: Basildon Hospital (Mid & South Essex NHS Trust); Royal College of Paediatrics and Child Health
AI-generated concerns summaryMany patients on long-term, high-dose opiate/opioid prescriptions for chronic pain lack support to reduce or cease their medication. There are no specialist services for prescription opiate dependence, as substance misuse services do not cover this area.
Addressed to: NHS Derby and Derbyshire Integrated Care Board
AI-generated concerns summaryThe coroner noted concerns regarding the extended period between multiple requests for a second banister rail and its installation by Darlington Borough Council, identifying a potential avoidable risk for tenants.
Addressed to: Darlington Borough Council
AI-generated concerns summaryThe coroner notes a national shortage of donor livers for children in the "super urgent" category, exacerbated by clinical guidance limiting suitable donors. This has increased wait times, raising a clear risk of lives being lost due to organ unavailability.
Addressed to: Department of Health and Social Care; NHS Blood and Transplant Service
AI-generated concerns summaryThe coroner identified a delay in obtaining adrenaline during resuscitation, likely due to a lack of standardised crash trolleys across hospitals. This causes confusion for junior doctors who frequently rotate and encounter different set-ups during critical moments.
Addressed to: Aneurin Bevan University Health Board; Betsi Cadwaladr University Health Board; Cabinet Secretary for Health and Social Care; Cardiff & Vale University Health Board; Cwm Taf Morgannwg University Health; Department of Health and Social Care; Hywel Dda University Health Board; Powys Teaching Health Board; Swansea Bay University Health Board; Velindre University NHS Trust
AI-generated concerns summaryThe coroner noted a lack of safety equipment and warning signage near the canal, which made it difficult for individuals to exit the water without assistance, especially given the proximity to student accommodation.
Addressed to: Canal & River Trust