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 identified gaps in specialist training for officers in sexual offences units, deficiencies in a sexual assault investigation, and unclear referral processes. Concerns were also raised about insufficient direct communication with the complainant regarding police decisions and the mishandling of a missing person's report.
Addressed to: South Yorkshire Police HQ
AI-generated concerns summaryA gross failure in monitoring and managing foetal heart rate during labour was identified, which experts linked to the death. The coroner questioned if current training prevents recurrence, and noted concerns that 100 units may follow incorrect guidelines.
Addressed to: Department of Health and Social Care; East and North Hertfordshire NHS Trust
AI-generated concerns summaryThe coroner identified issues with the NHS 111 assessment pathway not adequately considering patient history, alongside the closure of a call by CCAS due to an incorrect number, which resulted in a missed opportunity for medical investigation and treatment.
Addressed to: Covid-19 Pandemic Response Service and NHS Pathways
AI-generated concerns summaryThe Trust's head injury policy was not updated to reflect September 2019 NICE guidance, which advises a CT scan within 8 hours for patients on any anticoagulant. This meant the deceased, who was on enoxaparin, experienced a significant delay in receiving a CT scan after a head injury.
Addressed to: University Hospital Southampton NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inconsistent patient observation practices, with staff not always entering rooms, leading to uncertainty about when a patient was last seen. Additional concerns included deficiencies in mental health review, care planning, and record keeping, as well as insufficient staff for escorting sectioned patients.
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified risks in virtual primary care consultations due to difficulty assessing patient understanding and lack of written follow-up. Additionally, concerns were raised about the absence of standardised initial questions for clinicians triaging 111/999 calls and inaccurate recording from EPRs onto patient leaflets by paramedics.
Addressed to: NHS England; Yorkshire Ambulance Service
AI-generated concerns summaryThe Coventry and Warwickshire Partnership NHS Trust's Section 17 Leave Policy for detained patients requires clearer guidance on escorted leave, including verification of escorts and confirmation that patients leave with them. The report also notes insufficient time allocated for staff handovers.
Addressed to: Chief Executive and Mental Health lead for Coventry and Warwickshire Partnership NHS Trust
AI-generated concerns summaryThe coroner noted inadequate documentation of a patient declining hospital admission and the advice provided, alongside a lack of information for the family on deterioration signs. Further concerns included no contact with the patient's GP or family, despite the patient living alone.
Addressed to: West Midlands Ambulance Service
AI-generated concerns summaryThe coroner raised concerns regarding the interpretation of Public Health England guidance on patient movement to Covid-19 isolation wards, noting that varied interpretations across trusts could put vulnerable patients at risk of infection.
Addressed to: NHS England; Public Health England
AI-generated concerns summaryThe coroner identified no clear written policy for informal patients requesting leave from an Acute Care Unit, specifically regarding risk assessments and risk management. Concerns also included outstanding aspects of a protocol for managing alcohol detoxification on mental health wards.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryA lack of notification to the existing GP when the Personal Demographics service is updated or amended was identified.
Addressed to: NHS Digital
AI-generated concerns summaryThe care home lacked a clear policy for handling residents' hazardous personal property, and a sensor mat failed to alert staff to the deceased being out of bed. There was no rapid learning exercise after the incident, and policy reviews lacked completion deadlines.
Addressed to: Alexandra View Care Home
AI-generated concerns summaryThe coroner noted a potential link between SSRIs and suicidal thinking in young adults. They suggested a 'Black Box Warning' on medication packaging could more effectively highlight this increased risk to patients.
Addressed to: Department of Health and Social Care; Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted that despite a prescription for single daily dosage bottles, large multi-dose methadone bottles were supplied without a measuring device or instructions for accurate daily dosing.
Addressed to: Public Health England, General Pharmaceutical Council and Haverhill Pharmacy
AI-generated concerns summaryThe coroner identified the absence of a national database for gas appliances, noting that a lack of mandatory recording hinders communication between parties and makes tracing potentially dangerous items difficult and time-consuming.
Addressed to: Department of Business, Energy and Industrial Strategy; Office for Product Safety and Standards
AI-generated concerns summaryThe coroner questioned whether appropriate procedures were in place to consider sectioning the deceased under the Mental Health Act prior to his death.
Addressed to: United Lincolnshire Hospitals Trust
AI-generated concerns summaryThe coroner noted that the procedure for urgent adult social care assessments is overly bureaucratic and these referrals are not given sufficient priority within social services.
Addressed to: Milton Keynes Council and Social Services
AI-generated concerns summaryThe coroner noted public misunderstanding of electrocution risk due to inadequate and unupdated signage at Canterbury East Station. Concerns were also raised about unimplemented recommendations for under-platform warnings and inconsistent management of station access points when unstaffed.
Addressed to: London and South Eastern Railway
AI-generated concerns summaryThe coroner noted a patient's allergy was not recorded correctly due to a lack of interoperability between various electronic patient record systems in primary and secondary care. The CAMIS system was specifically identified as lacking an allergy recording field.
Addressed to: CaMIS PAS; Department of Health and Social Care
AI-generated concerns summaryThe patient was positioned out of sight from the nurses' station, and the dialysis equipment's alarm was insufficiently sensitive to promptly detect significant blood loss from a dislodged needle.
Addressed to: Department of Health and Social Care; Royal London Hospital