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 summaryThe coroner identified inadequate falls risk assessment, mobility care planning, and patient monitoring. Additional concerns included delayed medical assessment for a potential intracranial bleed and insufficient communication of clinical records after a fall.
Addressed to: Barts Health NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified inadequate information sharing and system connectivity between agencies. The GP safeguarding referral form for vulnerable adults with learning difficulties was found not tailored to GP input, risking incomplete information and delayed responses.
Addressed to: Derby City Council; Derbyshire County Council
AI-generated concerns summaryThe coroner noted that despite a patient with advanced dementia needing support with diet and fluids, he was admitted to hospital dehydrated and having not opened his bowels for seven days.
Addressed to: Caring UK
AI-generated concerns summaryThe coroner identified significant ambulance response delays beyond initial estimates and the lack of a system for the ambulance service to communicate unforeseen further delays to callers. This absence of follow-up risks patient deterioration, as callers may wait based on outdated information while conditions worsen from Category 2 to Category …
Addressed to: North West Ambulance Service
AI-generated concerns summaryThe coroner identified a risk that patients could be discharged home without consistently demonstrating the ability to use stairs unassisted, based on evidence that current discharge practices might still permit this.
Addressed to: County Durham & Darlington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a gap in the Tees, Esk and Wear Valley NHS Foundation Trust's Section 17 leave policy, as new processes for discussing and agreeing leave plans were not referenced in the updated policy document. A review of the policy was not anticipated until September 2026.
Addressed to: TEWV
AI-generated concerns summaryDelays were identified in providing a careline/lifeline pendant for a patient at high risk of falls after hospital discharge, alongside discrepancies in records concerning its installation.
Addressed to: Worcestershire County Council
AI-generated concerns summaryThe current processes for assessing patient discharge safety appear to have created an unrealistic impression of the patient's mobility.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe falls risk assessment was inaccurate and not updated as required, and associated patient documentation was incomplete.
Addressed to: HUTH
AI-generated concerns summaryThe coroner noted a 23-hour and 20-minute ambulance delay for a stroke patient, attributed to unprecedented demand, significant hospital handover delays, and limited social care provision. Concerns remain regarding ambulance response times due to these multifactorial reasons.
Addressed to: Cabinet Secretary for Health and Social Care; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted partially completed and inaccurate fluid and diet charts, confusion surrounding specific dietary requirements, and limited suitable food options for patients with particular needs.
Addressed to: Northampton General Hospital
AI-generated concerns summaryThe coroner noted a 23-hour delay in Mr Williams being seen by a custody nurse and an inadequate clinical assessment before prescribing. Separately, concerns for Serco included staff failing to promptly administer first aid or follow emergency procedures, and insufficient first aid training.
Addressed to: Metropolitan Police Service; Serco Prison Transport Services
AI-generated concerns summaryDespite multiple choking risk factors for Mrs Fenwick, a referral to Speech and Language Therapy (SALT) was not made. The coroner identified concerns regarding the threshold for SALT intervention and current waiting lists.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe shared care guideline for oral methotrexate has an outdated dose regime and does not reflect current professional responsibilities under the 'Pharmacy First' scheme, potentially delaying treatment for toxicity.
Addressed to: Greater Manchester Medicines Management Group
AI-generated concerns summaryThe coroner noted that a housing association property, managed by Squared (Luton Community Housing Ltd), had two incorrectly installed battery-operated smoke alarms.
Addressed to: Luton Community Housing Ltd
AI-generated concerns summaryThe coroner noted the absence of a formal s.117 plan upon a patient's discharge, which risked disjointed support for vulnerable individuals. Concerns were also raised about the lack of national guidance detailing the required elements for s.117 plans.
Addressed to: Birmingham and Solihull Mental Health Foundation Trust; NHS England
AI-generated concerns summaryThe coroner noted a lack of mandatory ACCT refresher training for prison officers at HMP Wandsworth and no procedures to ensure agency staff receive equivalent ACCT training. Furthermore, ACCT induction training does not include principles of risk formulation.
Addressed to: HMP Wandsworth; NHS England; Oxleas
AI-generated concerns summaryThe coroner noted a lack of clarity in Greater Manchester's Right Care Right Person system regarding how families are signposted to mental health services and how those services respond to mental health emergencies when police decline attendance. It was unclear what provision existed for mental health services to deal with …
Addressed to: Deputy Mayor of Greater Manchester; Greater Manchester Integrated Care Board
AI-generated concerns summaryThe coroner identified a lack of effective processes to ensure GPs receive complete patient information, including initial and amended ECG reports, before making important clinical decisions.
Addressed to: Broomwell Health Watch LYD; Crescent Surgery
AI-generated concerns summaryThe coroner noted conflicting policies between the prison healthcare provider and prison staff regarding prisoners suspected of being under the influence of illicit substances. This resulted in confusion, a lack of awareness, and a prisoner's clinical deterioration not being recognised or escalated due to missed observations.
Addressed to: HMP Bedford; Ministry of Justice; Northamptonshire Healthcare Foundation Trust