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 ward layout made patient observation difficult, especially for remote rooms, which increased risk for vulnerable patients. There was no clear protocol for staff to escalate risk or increase observation for patients after trigger events, leaving junior staff to make critical decisions.
Addressed to: Cheshire and Wirral Partnership NHS Foundation Trust
AI-generated concerns summaryMiscommunications among paediatric staff meant concerns regarding Aman were not properly considered prior to discharge, and the doctor authorising discharge did not review the most recent clinical observations. The Paediatric Emergency Department also operated in a frequently pressurised environment due to high patient numbers.
Addressed to: Department of Health and Social Care; Royal London Hospital
AI-generated concerns summaryBUPA's smoking risk assessment process and documentation did not sufficiently recognise or mitigate risks for immobile residents who smoke outside and cannot summon help. There were also gaps in recording offered risk mitigation measures and choices against professional advice.
Addressed to: BUPA, Lewisham Adult Safeguarding Board and Care Quality Commission
AI-generated concerns summaryThe coroner identified concerns regarding the current legal framework, which allows individuals to purchase and own a car without holding a valid driving licence. They noted that addressing this would require significant legislative changes.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted insufficient direct and confidential access for British Pregnancy Advisory Service (BPAS) patients with pregnancy-related mental health decline to perinatal psychiatry teams, as BPAS lacks direct access and GP referrals are not viable for those seeking anonymity.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted concerns about the dangerous junction of Goitre Lane and the Gurnos Ring Road due to poor visibility and increased danger from school traffic. Changes are needed to slow drivers on the Ring Road.
Addressed to: Merthyr Tydfil County Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding the safety of standalone midwife-led birthing centres versus those with immediate hospital access, along with the recruitment and retention of midwives to ensure continuity of care, and the improved detection of babies who are of small gestational age.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the prison did not comply with national policy regarding the retention and preservation of evidence following a death in custody. This repeated local issue prevents full examination of facts and learning, thereby increasing the risk of future deaths.
Addressed to: HMP Lowdham Grange
AI-generated concerns summaryThe coroner noted that a specific risk regarding medication misuse was not documented, assessed, or managed, and the Trust's internal investigation did not identify this as a failing.
Addressed to: East London Foundation Trust
AI-generated concerns summaryThe ligature risk reduction policy and audit tools do not provide guidance on minimising potential ligatures, such as items of clothing. The policy prioritises avoiding blanket restrictions over identifying real risks, and should be improved to recognise and address specific clothing items as ligature risks.
Addressed to: NHS England; NHS Improvement
AI-generated concerns summaryThe coroner identified issues with an untrained call handler not speaking directly with the caller, a blanket policy preventing discussion with callers, and insufficient action taken with information received. Consideration was also recommended for recording incoming calls.
Addressed to: Midlands Partnership NHS Foundation trust
AI-generated concerns summaryThe coroner noted insufficient training and supervision for an 18-year-old employee, overdue maintenance and safety defects on FLTs, and a lack of established health and safety systems at the company. No evidence of health and safety improvements was provided almost two years after the death.
Addressed to: Lincs Firwood Co Ltd and DD Dodds and Son ltd
AI-generated concerns summaryThe coroner noted concerns that the general practitioner was not routinely invited to Multi-Agency Risk Assessment Conference (MARAC) meetings or informed of domestic abuse allegations and care proceedings, which impacted the patient's mental health treatment.
Addressed to: Domestic Abuse Management Board Surrey Police; Surrey County Council
AI-generated concerns summaryThe coroner noted limited visibility for pedestrians and motorists at an A44 footpath crossing and suggested reviewing foliage, safety barriers, the crossing's nature, traffic speed, and signage.
Addressed to: Herefordshire Council and Balfour Beatty Living Places
AI-generated concerns summaryThe coroner raised concerns regarding insufficient cascading of vital care and risk information from team leaders to direct care staff, and a lack of instruction and time for staff to familiarise themselves with resident care plans. There was also a noted lack of understanding of falls policies.
Addressed to: Elm Tree Court Care Home and HICA Group
AI-generated concerns summaryThe coroner noted a lack of structured training for all hostel workers regarding identifying risks of alcohol intoxication and recognising signs indicating a need for urgent medical intervention.
Addressed to: Tyne Housing Association
AI-generated concerns summaryThe coroner noted an inadequate assessment of the individual by NEAS Trust, a lack of comprehensive trust-wide learning from the incident, and the need for an urgent review of mental health incident policies and staff training.
Addressed to: North East Ambulance Service
AI-generated concerns summaryThere is no system at HMP Hewell to follow up discrepancies between a prisoner's declared mental health history on arrival and their community GP records, potentially overlooking significant past issues such as suicide attempts.
Addressed to: HMP Hewell; Practice Plus Group
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clear guidance on the timeframe for completing the 'Seven-day short stay booklet for admission/discharge' and what steps to take if it is not completed on admission day. Concerns were also raised about the absence of guidance on how to complete the booklet, particularly regarding …
Addressed to: Surrey and Sussex Healthcare NHS Trust