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 summaryInsufficient mental health assessment and follow-up by the General Practitioner were noted, alongside the practice's lack of prescribing policies, training, and robust clinical governance. TalkPlus also lacked clear guidance for secondary mental health service referrals.
Addressed to: NHS England, Department of Health, Care Quality Commission, General Medical Council, Surrey Clinical Commissioning Group, GP and Farnham Park GP Practice
AI-generated concerns summaryThe coroner noted approximately 100 suicides occur annually within the health service profession. The report highlights the need for this issue to be addressed to prevent future deaths in this vulnerable professional group.
Addressed to: Royal College of GPs, British Medical Association and Minister of State for Patient Safety, Suicide Prevention and Mental Health
AI-generated concerns summarySheffield Health and Social Care Trust's discharge plan for Mrs Grayson did not adequately reflect identified risks, contradicting Ministry of Justice clinical evidence and failing to integrate recommendations. Concerns were also raised about risk assessments placing an undue burden on her family for communication.
Addressed to: Ministry of Justice; Sheffield Health and Social Care NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the cot's age and maintenance, the lack of guidance for its padded board, and inadequate overnight monitoring of the child. Significant issues were identified regarding the Children's Trust's investigation, which lacked transparency and failed to fully inform statutory bodies or preserve the scene.
Addressed to: Care Quality Commission; Department of Health and Social Care; NHS England; Sheffield Clinical Commissioning Group; Tadworth Children’s Trust
AI-generated concerns summaryThe coroner noted inadequate training and a general lack of awareness among medical professionals, including GPs and hospital doctors, regarding the risk of sepsis following Early Medical Terminations, which meant sepsis protocols were not initiated.
Addressed to: Department of Health & Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the layout of a busy road junction, the 50mph speed limit on Cadishead Way, and restricted visibility for vehicles exiting Fairhills Road due to trees and bushes.
Addressed to: Salford City Council
AI-generated concerns summaryThe coroner noted inadequate information sharing between multiple agencies regarding the person's drug relapse, raising concerns about the lack of a universal approach to inter-agency cooperation and the absence of central points of contact for information exchange and referrals.
Addressed to: Probation Service – Young Adults Central Team, Birmingham Women’s and Children’s NHS Foundation Trust, Change Grow Live and Forward Thinking Birmingam
AI-generated concerns summaryThe coroner noted that the Mental Health Trust's capacity and resources, especially during staff absences, influenced engagement with a perpetrator and the ability to cover necessary work.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; Health and Social Care
AI-generated concerns summaryThe coroner noted the absence of statutory requirements or mandatory regulations for fitting ligature alarms in newly built mental health units, and that existing guidance for anti-ligature fixtures is not mandatory.
Addressed to: Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner identified concerns regarding the improper preparation of food, inadequate feeding practices by carers, and staff's failure to provide appropriate choking first aid. There were also significant issues with nursing staff not recognising cardiac arrest or performing effective CPR, indicating a need for frequent training.
Addressed to: BUPA Care Services and Highgate Care Home
AI-generated concerns summaryThe coroner noted a lack of a protocol governing steps to safeguard individuals who are alone and at risk in the community while awaiting Mental Health Act assessments.
Addressed to: NHS England; Royal College of Psychiatrists
AI-generated concerns summaryA requested echocardiogram was not performed prior to surgery, and the patient was not recently reviewed by the orthopaedic surgeon. There was a lack of funding and resources for a dedicated high-risk consultant-led anaesthetic pre-operative assessment clinic.
Addressed to: St Peter’s Hospital
AI-generated concerns summaryThe coroner noted a lack of clear written instructions and an audit process for conducting welfare checks. Concerns were also raised regarding the clarity of responsibility for task lists, particularly during night shifts when agency staff are used.
Addressed to: Practice Plus Group; The Ministry of Justice, Justice and Development Division, Litigation Group, Government Legal Department
AI-generated concerns summaryThe coroner identified that restrictions in cardiac surgical capacity at SGH are leading to patient diversions and increased risk of death. Concerns were also raised about the inadequacy of the Service Justification Review process, impacting patient safety and staff morale.
Addressed to: NHS England; St George’s Hospital
AI-generated concerns summaryA hedge at the junction of Green Lane and the A525 obstructs the view for vehicles joining the main road, which poses an ongoing risk of collisions.
Addressed to: Hollybush House, Green Lane, Bangor on Dee, Wrexham; Wrexham County Borough Council
AI-generated concerns summaryThe coroner noted that care staff provided Oramorph without checking its contents and that a medical review might have been appropriate after the individual disclosed taking an excess dose.
Addressed to: Cherish Home Care
AI-generated concerns summaryThe coroner noted delays in fully implementing a new Standard Operating Procedure for managing irregular scan reports and a lack of an audit process to ensure its effectiveness, which allows known risks to patients to continue.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryThe ambulance crew were unaware that seizures combined with cocaine constituted a medical emergency, affecting the urgency of transport and access to appropriate treatment. The assessment of urgency by ambulance staff was also unduly influenced by the suspected link between his arrest and seizures.
Addressed to: London Ambulance Services NHS Trust
AI-generated concerns summaryGreater Manchester Mental Health NHS Foundation Trust's use of separate record-keeping systems limited staff access to patient information for risk assessments, and its safeguarding policy was not followed. Concerns were also raised about mental health service design not being consistently trauma-informed.
Addressed to: Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryNo system to identify appropriate antibiotic forms for frail patients delayed treatment. Communication via the 'ASK MY GP' system was difficult, and insufficient face-to-face GP assessment delayed recognition of patient deterioration.
Addressed to: Greater Manchester Health and Social Care Partnership; Trafford Clinical Commissioning Group