Browse 6,471 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 noted a lack of risk assessment for Ms Karat's flat, specifically the window opening onto an unsafe balcony without railings, warning signs, or restrictors. There was also no clear communication to Ms Karat about unauthorised balcony use.
Addressed to: Clarion Housing Group
AI-generated concerns summaryThe coroner identified gaps in online prescribing, including no central tracking system for dispensed medications, a lack of mandatory GP notification, and insufficient face-to-face consultations. Concerns also noted easily manipulated patient questionnaires and limited regulation.
Addressed to: Care Quality Commission; Department of Health and Social Care; General Medical Council; General Pharmaceutical Council; NHS England
AI-generated concerns summaryThe report described serious deficiencies in the management of Usman Khan, including insufficient experience, training, and psychological assessment. It also highlighted a lack of communication and an incomplete risk assessment for the event, along with missed opportunities for expert guidance.
Addressed to: College of Policing; Department for Education; Home Office; Learning Together Network CIC; Ministry of Justice; Office for Students; Staffordshire Police; Security Service; University of Cambridge; West Midlands Police
AI-generated concerns summaryThe coroner noted that the patient allocation system required manual checks, meaning patients could be missed for assessment, and the electronic prescribing system lacked a secondary check for medication selection, risking incorrect medication administration.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need for specialist dual diagnosis services, including outreach and drop-in centres, to support individuals experiencing mental health crises alongside substance abuse, who are often denied mental health care.
Addressed to: Brighton and Hove City Council; Change Grow Live (Surrey and Borders NHS Trust); Department of Health and Social Care; NHS Brighton and Hove Clinical Commissioning Group; Sussex Partnership Foundation Trust
AI-generated concerns summaryThe coroner identified delays in adopting a proposed N-Acetylcysteine administration protocol and in implementing diagnostic results procedures by a stated deadline. The report raises concerns about the Health Board's timely implementation of changes.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted no system for monitoring compliance with equipment use instructions and a lack of guidance on the appropriate circumstances for using specific prescribed equipment.
Addressed to: Abbeyfields the Dales Ltd and North Yorkshire County Council
AI-generated concerns summaryThe coroner noted frequent changes in Mr. Walker's care co-ordinators, many of whom were locum staff, hindering therapeutic relationships. Additionally, collateral information from other Trusts was not sought upon hospital admission, a requirement missing from the admission checklist.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a national policy or local protocol at the time of death for welfare checks and monitoring prisoners found under the influence of psychoactive substances, despite the known risks of deterioration and self-harm.
Addressed to: Department of Health and Social Care; HM Prison and Probation Service; NHS England and NHS Digital
AI-generated concerns summaryInformation about Mr Franks' stated intent to commit suicide and distress at court was not communicated to prison staff, which prevented an ACCT assessment and increased monitoring. The coroner noted that sharing such protective information does not breach professional privilege.
Addressed to: David Ake & Co Solicitors
AI-generated concerns summaryThe coroner identified that 18-year-old patients transferring from CAMHS immediately receive adult mental health provisions, despite the lack of a dedicated inpatient provision for individuals aged 14-25. This gap creates a risk of further deaths.
Addressed to: NHS England; North Staffordshire Combined Healthcare
AI-generated concerns summaryThe report highlights delays in accessing mental health assessments and psychological therapy due to challenges in balancing service capacity with increasing demand, and difficulties in recruiting and retaining skilled staff within the Trust.
Addressed to: Hellesdon Hospital
AI-generated concerns summaryThe coroner noted the absence of a birth plan, meaning the mother's preferences for care during labour were not recorded. Concerns were raised regarding the use of Kielland's forceps, which caused a catastrophic spinal cord injury, with a recommendation for an urgent review.
Addressed to: Milton Keynes University Hospital NHS Foundation Trust; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted that managers misunderstood and inaccurately completed risk assessments, leading to concerns that risk screenings for other residents in the Avenues Group may also have similar inaccuracies. This suggests a need for improved understanding and training regarding the risk assessment process.
Addressed to: Avenues Trust Group
AI-generated concerns summaryThe coroner raised concerns that unmonitored police work mobile phones, given to vulnerable people, could delay urgent responses when officers are off duty, and noted a lack of clear escalation policies or audit trails for these direct contacts.
Addressed to: National Police Chiefs’ Council, Home Office, College of Policing and Victims Commissioner for England
AI-generated concerns summaryInadequate communication and transfer processes between mental health teams and general practitioners led to insufficient follow-up and unprescribed medication. Concerns also included a lack of escalation protocols for patient disengagement and gaps in medication monitoring.
Addressed to: Prestwich Hospital and The Droylsden Road Family GP Practice
AI-generated concerns summaryThe coroner noted that a Root Cause Analysis investigating a missed medication dose was not sufficiently rigorous, as it failed to examine the factors leading to the omission or its consequences. This raised questions about organisational governance standards and learning from deaths.
Addressed to: Northern Care Alliance NHS Trust
AI-generated concerns summaryThe coroner noted a lack of clarity among care staff regarding when to escalate acutely unwell residents to emergency services and the role of the enhanced care team. There were also poor procedures for identifying residents' DNAR status.
Addressed to: Manor Court Healthcare on behalf of Anson Court Residential Home and Walsall Manor Hospital
AI-generated concerns summaryThe coroner noted a lack of user knowledge regarding the risks of rapid oxygen release from cylinders and the potential for ignition due to adiabatic compression or particle impact when valves are incorrectly opened. Multiple similar incidents have been reported, with investigations ongoing.
Addressed to: Medicines and Healthcare Products Regulatory Agency, Health and Safety Executive, West Midlands Ambulance Service and Care Quality Commission
AI-generated concerns summaryThe coroner noted a system failure in the hospital's discharge process and that significant hypothyroidism indicated by blood tests in August 2020 and April 2021 was not flagged or acted upon.
Addressed to: Warwick Hospital