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 summaryConcerns included the Crisis Resolution Team's (CRT) failure to ensure Mr Lennon was on an appropriate mental health pathway and a flawed review that did not identify his deteriorating mental state. Furthermore, a serious incident action plan was found to be incomplete due to governance errors.
Addressed to: Department of Health and Social Care, East London Foundation NHS Trust and NHS England; The National Quality Board
AI-generated concerns summaryThe coroner identified a significant gap in support for vulnerable young people awaiting substantive mental health treatment, exacerbated by long waiting lists for psychological therapies and difficulties meeting urgent intervention criteria. This situation poses risks for individuals at chronic risk of impulsive acts.
Addressed to: Cambridgeshire and Peterborough NHS Foundation Trust and Cambridgeshire County Council
AI-generated concerns summaryThe coroner noted that care in ICU was not escalated appropriately despite full staffing, and that NEWS scores were not accurately calculated or documented, alongside generally poor documentation.
Addressed to: East & North Hertfordshire NHS Trust
AI-generated concerns summaryCare home staff were unaware of specific dietary recommendations in the care plan for a resident with Parkinson's disease. They generally did not access or utilise key information contained in care plans and risk assessments.
Addressed to: Ashley Gardens Care Centre; Care Quality Commission
AI-generated concerns summaryThe coroner identified gaps in coordinated care and joint assessment for vulnerable adults with complex mental health and social care needs, leading to no comprehensive care plan and insufficient understanding of personal risks.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summarySprinkler systems are not a mandatory requirement for care homes with immobile occupants, and such homes are not deemed 'Higher Risk Buildings' unless they meet specific height or storey criteria, despite occupant vulnerability.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner identified gaps in VTE risk assessment for patients with reduced mobility, insufficient detail in clinical notes and care plans, and a need for improved junior staff consultation on medication interactions.
Addressed to: Hellesdon Hospital
AI-generated concerns summaryA junior doctor misheard a senior colleague's verbal instruction for phenytoin dosage, leading to a significant overdose. The coroner noted the risk of confusion from similar-sounding numbers in verbal communication within hospitals.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted significant delays in standard referral waiting times and the absence of a national protocol for dentists to provide photographs and detailed information in secondary care referrals, which impacts triage quality.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that Mr Stroud's case was not discussed at a Multi-Disciplinary Team (MDT) meeting. Concerns were raised about the Care Coordinator making clinical decisions, such as not referring to an MDT, without documenting the rationale.
Addressed to: Essex Partnership University Trust and NHS England
AI-generated concerns summaryThe coroner noted that mental health ward environments could be chaotic and unsuitable for patient recovery due to resource constraints, alongside lengthy waits for psychological therapies, averaging one year locally.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe initial 999 call processing for a massive overdose did not adequately convey its time-critical nature, leading to a delayed emergency response. This was compounded by a missed opportunity to upgrade the response and inconsistent categorisations of subsequent calls.
Addressed to: Welsh Ambulance NHS Trust
AI-generated concerns summaryConcerns included inadequate assessment and monitoring during psychiatric medication changes, with inappropriate prescribing practices and poor record-keeping. There was also a missed urgent psychiatric referral due to a doctor's lack of understanding of prescribed drugs.
Addressed to: Broadgate General Practice; General Medical Council
AI-generated concerns summaryThe coroner raised concerns regarding the absence of adequate lighting and warning signage at a specific point on the A66 where vehicles cross from a café. Further issues included the speed of traffic and the insufficient width of the central reservation for large vehicles.
Addressed to: Cumbria County Council; National Highways
AI-generated concerns summaryThe coroner notes a lack of available residential and EMI nursing placements for elderly individuals in Gwynedd, which delays access to appropriate care as their cognitive and physical needs change.
Addressed to: Minister for Health and Social Services and Gwynedd Council
AI-generated concerns summaryThe coroner raises concerns that the indirect process for sharing Public Protection Notices (PPNs) with General Practitioners for residents in the Dorset Council area may prevent GPs from receiving critical information. This can lead to missed opportunities for patient assessment and support.
Addressed to: Dorset Council; Dorset Police
AI-generated concerns summaryThe coroner noted no evidence that sensitive issues in a self-assessment form were discussed with Jake by a professional before completion. Youth Justice Board guidance also lacks express reference to considering such discussions with vulnerable young persons.
Addressed to: Youth Justice Board for England and Wales
AI-generated concerns summaryThe coroner notes insufficient understanding of Autism among child mental health referral staff, and a risk of inappropriate closure or referral for children needing clinical assessment. Concerns also relate to automatically categorising routine referrals as "low risk", which can delay care for children at higher risk.
Addressed to: Department for Education; Department of Health and Social Care; National Child Safeguarding Review Panel; Surrey and Borders Partnership NHS Foundation Trust; Surrey County Council; Surrey Heartlands Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted a disparity in information and advice for detained prisoners awaiting deportation, with limited access to support and ineffective communication between the prison and Home Office regarding their cases.
Addressed to: Home Office
AI-generated concerns summaryMill View Hospital's reliance on police to return absconding patients is noted, due to insufficient staff and underutilised Mental Health Act powers. There are also gaps in the joint absent without leave policy regarding risk assessment grading and communication with police.
Addressed to: Sussex Partnership NHS Foundation Trust; Sussex Police