Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryConcerns included the unregulated status of Ayurvedic practitioners and medicines, inadequate awareness among practitioners of potential harm, and a GP's consultation that lacked detailed examination or timely advice for the patient.
Addressed to: Ayurvedic Professionals Association; Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; Enterprise Practice
AI-generated concerns summaryThe coroner identified insufficient exploration of autism's impact in risk assessments, inadequate consideration of higher suicide prevalence in autistic individuals, and a lack of sufficient reasonable adjustments. Gaps were also noted in staff understanding and access to specialist autism support.
Addressed to: Humber & North Yorkshire Health and Care Partnership; NHS England; NHS Improvement
AI-generated concerns summaryThe coroner identified delays in both the insertion of a required NG tube and the acceptance of a patient transfer between hospitals. There was also a lack of clear policies and procedures for transferring patients under a section and their necessary documentation.
Addressed to: Barnsley District General Hospital and Kendray Hospital
AI-generated concerns summaryThe coroner identified a lack of escalation for the patient's deterioration and pain, alongside the absence of comprehensive care plans, risk assessments, and proper management of pressure ulcers. Staff training and escalation procedures were inadequate.
Addressed to: Care Quality Commission; Litch Care for Action
AI-generated concerns summaryThe coroner raises concerns about the adequacy of psychiatric doctor provision at HMP Leeds, noting that limited availability can lead to significant delays in assessing prisoners with mental health issues, including those with suspected psychotic features. Similar delays have been identified in previous cases.
Addressed to: Practice Plus Group Health and Rehabilitation Services Limited
AI-generated concerns summaryThe coroner noted that Mr Xavier's dangerously elevated creatinine levels were not acted upon prior to his discharge from hospital, and his referral to the surgical team was chaotic with no formal handover or review of clinical records. Insufficient regard was also given to his learning disability when taking his …
Addressed to: Barts Health NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified issues with inadequate contemporaneous clinical record-keeping and communication among staff, along with incomplete patient observations and care plans. Further concerns noted patients' access to ligatures, insufficient staff training and supervision, and a lack of clear clinical assessment for repeated self-harm attempts.
Addressed to: Alternative Futures Group; Greater Manchester Mental Health NHS Foundation Trust; Safety Matters (Legal) Limited; Safety Matters Ltd
AI-generated concerns summaryThe coroner raised concerns about inconsistencies in risk assessment and triage within the First Response Service. Insufficient time for practitioners to gather information and properly assess risk, stemming from resource pressures, staffing difficulties, and funding discrepancies, creates a risk of future deaths.
Addressed to: Department of Health and Social Care; Ipswich and East Suffolk Clinical Commissioning Group
AI-generated concerns summaryThe current system and training for police drivers does not provide them with sufficient information to determine if other units are closer, which prevents them from completing a full risk assessment before responding to emergency calls.
Addressed to: Metropolitan Police Service, The College of Policing and The National Police Chief Council
AI-generated concerns summaryThe coroner noted that the Pathology Department is significantly under-resourced and asked for a review of consultant staffing levels, particularly for thoracic work, to ensure timely and accurate diagnoses.
Addressed to: University Hospitals Plymouth NHS Trust
AI-generated concerns summaryThe coroner noted the prolonged prescription of a short-term insomnia medication for 20 years without meaningful review by the GP or mental health team. Concerns were also raised about the lack of monitoring for PRN administration frequency and failure to share evidence of dependence between services.
Addressed to: North East London Foundation Trust and High St Surgery
AI-generated concerns summaryAn incomplete psychiatric assessment and insufficient risk assessment failed to appraise suicide risk factors or manage the patient's risks. There was a lack of inquiry into a prior attempt by the patient to give himself a stroke, and no evidence that his wife had the opportunity to contribute to clinical …
Addressed to: Portland Practice, Central and North West London NHS Foundation Trust, Imperial College health Care NHS Trust and West London NHS Trust
AI-generated concerns summaryThe coroner identified limited staffing and CCTV surveillance at Portchester Railway Station, an 'escalated' location with multiple fatalities where previous security recommendations were not fully addressed. Public security and welfare announcements were also lacking.
Addressed to: South Western Railway and BTP Fatal Investigations Officer
AI-generated concerns summaryNorth West Ambulance Service NHS Foundation Trust is routinely not meeting national target response times for emergency calls, with evidence showing significant delays for category 2 calls on specific dates.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about a low wall providing insufficient protection from an 8-10 foot drop into a rock-strewn river, especially as the area is unlit at night.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner raises concerns about the absence of commissioned psychiatrists in Liaison and Diversion (L&D) services, limiting practitioners' ability to identify serious mental illness. This is compounded by police misunderstanding L&D's role and reduced availability of Forensic Medical Examiners.
Addressed to: NHS England, Birmingham and Solihull Mental Health, Home Office and West Midlands Police
AI-generated concerns summaryThe coroner expressed concern that the Hands of Light Academy dispensed hallucinogenic substances to attendees, potentially including mentally unwell individuals, without adequate consideration of the impact, particularly on those with psychosis.
Addressed to: Hands of Light Academy
AI-generated concerns summaryThe coroner identified a lack of Metropolitan Police policy regarding the use of handcuffs when medical staff request their application to a patient in hospital for treatment of a medical condition.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner noted insufficient lighting and signage near a stream and railway fence, including a lack of warnings about the stream's danger or guidance for exiting the venue. Additionally, the railway fence was inadequate to prevent access to the tracks.
Addressed to: Thames Water, Alexandra Palace and Network Rail
AI-generated concerns summaryThe coroner identified a practice where telephone workers bypassed specialist mental health assessments, making risk judgments on limited criteria. Issues included a lack of care co-ordination and clarity in the multi-disciplinary team's discharge decisions and approach to re-referrals.
Addressed to: Nottinghamshire Healthcare Trust and Turning Point