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 noted repeated deficiencies in the ACCT process, an inefficient reception process leading to the loss of vital prisoner information, and the suspension of suicide and self-harm training for staff despite a high risk of self-inflicted deaths.
Addressed to: HMP Pentonville; HMPPS; Ministry for Justice; Serco
AI-generated concerns summaryThe coroner noted ward staff failures to instigate MHA authorisations or reassess Mr Zaman's risk level following incidents of absconding and aggression. Concerns also included delays in reporting him missing to police and inadequate documentation.
Addressed to: Department of Health and Social Care; East London Foundation NHS Trust
AI-generated concerns summaryThe coroner noted a continued significant influx of illicit drugs, including Class A and Novel Psychoactive Substances, into HMP Long Lartin. There were also failures in the ACCT process, where no support actions were entered onto the care plan despite multiple reviews.
Addressed to: Prison, Probation and Reducing Offending; Probation and Reducing Offending, Ministry of
AI-generated concerns summaryThe coroner noted a lack of national guidance for clinicians on when to consider and how to diagnose Autoimmune Encephalitis, which could lead to the condition not being identified and increase the risk of future deaths.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns about an ineffective patient records system for highlighting important information, and communication processes that hindered patient and family engagement in clinical decisions. Procedures for timely specialist stroke team input were also lacking.
Addressed to: West Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identified no mechanism for police officers to share mental health risk information regarding adults at medium risk to self with healthcare providers. This absence can impact future assessments and the provision of vital mental health support.
Addressed to: Suffolk Constabulary; Suffolk County Council
AI-generated concerns summaryThe coroner raises concerns about a lack of awareness among care and nursing staff regarding when CPR should be attempted, noting that other vulnerable residents with a realistic chance of survival could die from potentially reversible causes.
Addressed to: Care Quality Commission; Curo Care Delahey’s
AI-generated concerns summaryThe coroner noted that the full nature of the deceased's mental health deterioration and irrational behaviour was not appreciated as significant, leading to discharge with a conservative community-based care plan and no escalated home-based treatment.
Addressed to: Greater Manchester Integrated Care Partnership; Greater Manchester Mental Health
AI-generated concerns summaryThe coroner identified a lack of training for healthcare and prison staff in recognising Acute Behavioural Disturbance (ABD), leading to Mr Tarrant's condition not being identified. This absence of training persists despite ABD being a known condition referenced in a 2005 Prison Service Order.
Addressed to: HMP Elmley
AI-generated concerns summaryThe coroner identified a lack of training among prison and healthcare staff in recognising Acute Behavioural Disturbance (ABD), meaning Mr Tarrant's condition was not identified despite known risks and historical guidance on the matter.
Addressed to: Probation and Reducing Reoffending, Ministry of J; Prisons, Probation and Reducing Reoffending
AI-generated concerns summaryThe report identifies a lack of training for both healthcare and prison staff in recognising Acute Behavioural Disturbance (ABD), a condition carrying a risk of physiological collapse exacerbated by restraint. This meant Mr Tarrant's symptoms went unrecognised.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified inadequate procedures at HMP Norwich for releasing prisoners requiring mental health care, specifically regarding arranging follow-up. Concerns were also raised about insufficient information sharing with Probation Services and unclear guidance for released prisoners.
Addressed to: HM Prison, Probation and reducing offending
AI-generated concerns summaryThe coroner identified a lack of local or national guidance on the steps to take when a patient being monitored for clozapine returns a high serum level.
Addressed to: Midlands Partnership Foundation Trust; NHS England
AI-generated concerns summaryThe coroner identified concerns regarding the practice of downgrading NEWS scores for patients with COPD without knowing their baseline oxygen saturation levels, noting this unsafe practice required a more robust approach to clinical assessments.
Addressed to: Anueron Bevan University Health Board; Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified delays in medical review after a family member raised concerns about a patient's condition. Further concerns included insufficient nursing practices for vulnerable patients' hydration and nutrition, and that comparable communication improvements may not be Trust-wide.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryUnacceptable delays in referrals, assessments, and diagnoses for ASD and ADHD hinder care provision. The crisis team's gate-keeping of referrals, even from other psychiatric teams, also prevents access to urgent crisis care.
Addressed to: Department of Health and Social Care; West London NHS Trust
AI-generated concerns summaryThe coroner noted limited signage on the railway walkway gate, near a "decision point," which could be improved with clear pictorial signage to alert users, especially given increased earphone use affecting awareness.
Addressed to: Level Crossings and Public Safety; Level Crossing and Public Safety; North West Route Director; The Chief Coroner
AI-generated concerns summaryThe coroner noted a lack of proficiency among West Suffolk Hospital doctors in timely TIA Clinic referrals. Further concerns were raised about the absence of commissioned stroke consultant input for out-of-hours care at the hospital, affecting patient treatment.
Addressed to: Suffolk and North East Essex Integrated Care Board; West Suffolk NHS Foundation Trust
AI-generated concerns summaryThe consultant psychiatrist at Curaleaf lacked experience for Oliver's complex adult presentation, and the initial medicinal cannabis prescription was based on incomplete information, hindering Oliver from receiving appropriate psychiatric care.
Addressed to: Curaleaf Clinic
AI-generated concerns summaryThe coroner noted that not all staff at Royal Hospital School were proficient in using the CPOMS safeguarding system, leading to information not being recorded. There is also no single national safeguarding information management tool for schools, which could result in important details being missed due to staff unfamiliarity.
Addressed to: Department for Education; Minister for Women and Equalities; Royal Hospital School