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 insufficient Tier 4 Paediatric Mental Health beds and an average 8-day wait. Children needing mental health care are accommodated on acute paediatric wards not designed or staffed for their needs, lacking community care or specialist beds.
Addressed to: NHS England & NHS Improvement
AI-generated concerns summaryThe coroner noted that a single medical consultant is responsible for geriatric perioperative care without adequate cross-cover, creating a risk that urgent test results could be missed during their absence.
Addressed to: [REDACTED}, Chief Executive Cardiff & Vale University Health Board
AI-generated concerns summaryPrison windows and the gatehouse require upgrading to reduce the entry of illicit materials. Additionally, scheduled morning welfare checks were missed due to a lack of staff, a recurring issue.
Addressed to: Governor of HM Prison Parc
AI-generated concerns summaryThe coroner noted confusion among community pharmacists in Wales regarding their duty to perform clinical checks for safe prescribing, particularly concerning drug interactions and patient confidentiality when third parties collect medication. There are also concerns about pharmacists having limited access to the Welsh Clinical Portal for patient drug history, hindering …
Addressed to: Digital Health and Care, Wales; General Pharmaceutical Council; Health and Social Care for Wales; [REDACTED] Chief Executive Officer (CEO), NHS England, Wellington House, 133-155 Waterloo Road, London SE1 8UG
AI-generated concerns summaryThe coroner raises concerns that mental health assessments did not utilise detailed information from the Electronic Patient Report Form (EPRC) or contact family for collateral, due to gaps in training, practice, and policy among mental health nurses.
Addressed to: [REDACTED] Chief Executive Officer (CEO), NHS England, Wellington House, 133-155 Waterloo Road, London SE1 8UG
AI-generated concerns summaryThe coroner identified concerns regarding a hazardous right-turn manoeuvre at Moss Farm Shop due to road layout, lack of 'left-turn only' signage, and ineffective road markings. Ambiguity in legal guidance regarding right turns across double white lines was also noted.
Addressed to: Department of Transport; Moss Farm; National Highways
AI-generated concerns summaryThe coroner raises concerns regarding persistent ambulance delays and the ongoing unavailability of resources for the Welsh Ambulance Service Trust, noting that lives continue to be at risk despite multi-agency efforts to improve response times.
Addressed to: Welsh Ambulance Services University NHS Trust
AI-generated concerns summaryThe care home lacked clear policies on medication, escalation, and reporting concerns, alongside inadequate medical monitoring and management of infections, and insufficient escalation of concerns to Adult Social Care.
Addressed to: Cann House; Premiere Health Ltd
AI-generated concerns summaryInsufficient advice was provided regarding the risks of Candesartan during pregnancy, both at initial prescription and in subsequent consultations. The medication remained on repeat prescription and was approved without detailed review or system warnings after the patient became pregnant.
Addressed to: Riverview Surgery; Royal College of General Practitioners
AI-generated concerns summaryThe coroner noted the 'Offence Neutrality' policy in prisons risks future deaths by fostering an environment of fear, bullying, and abuse for prisoners convicted of sexual offences, leading to increased self-harm and self-isolation.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner noted concerns that a visual-only electronic sensor alarm on a CCTV system, lacking an audible component and displaying for only a few seconds, could be easily missed by operators, potentially leading to missed intervention opportunities.
Addressed to: MAPP; Hempstead Valley Shopping Centre; MAPP
AI-generated concerns summaryHospital doctors at Northampton General Hospital lack electronic access to detailed primary care medical notes, including GP and community mental health records. This absence of crucial information hinders their ability to provide comprehensive patient treatment and care, particularly for vulnerable patients.
Addressed to: Department of Health and Social Care; NHS England; Northampton General Hospital
AI-generated concerns summarySuboptimal staffing levels on Ward 90 hinder the provision of consistent TAG nursing care, thereby increasing patients' risk of falls.
Addressed to: Hull University Teaching Hospital; NHS England
AI-generated concerns summaryThe nightclub delayed calling an ambulance for a person exhibiting severe medical symptoms, which the coroner attributed to deficiencies in the club's training and overall culture for managing medical emergencies.
Addressed to: Fold Nightclub
AI-generated concerns summaryThe coroner noted a lack of national guidance for home births, including standards for midwife training, safe staffing, equipment, and hospital transfer thresholds. Concerns were also raised about the absence of national or local data collection on home birth outcomes.
Addressed to: Department of Health and Social Care; National Institution for health and care excellence; NHS England; Secretary of State for Health & Social Care
AI-generated concerns summaryConcerns were raised regarding inadequate and unclear handovers between police forces and the mental health trust, which resulted in the trust being unaware of significant patient risk factors. This impacts risk assessments and decisions about granting patient leave.
Addressed to: Greater Manchester Police; South Yorkshire Police
AI-generated concerns summaryThe coroner identified gaps in call handler training and understanding of procedures for hanging incidents, particularly concerning Category 1 response criteria. There were also concerns that the call handler did not follow the procedure to contact the person for more information.
Addressed to: Isle of Wight NHS Trust
AI-generated concerns summaryThe coroner noted inadequate falls risk assessments and care plans, insufficient oversight for their completion, and low night-time staffing levels at The Meadows Nursing Home, with potential implications for other homes operated by Cardinal Healthcare.
Addressed to: Cardinal Healthcare
AI-generated concerns summaryInadequate falls risk assessments and care plans, and insufficient oversight for documentation, were identified. The coroner also noted Cardinal Healthcare's failure to address low night-time staffing levels, risking residents in their other homes.
Addressed to: Cardinal Healthcare
AI-generated concerns summaryThe coroner raises concerns about the long detention of Imprisonment for Public Protection (IPP) prisoners beyond their original tariff, with many still awaiting parole review and lacking access to rehabilitation programmes. This situation impacts their mental health and reduces hope of release, posing a risk of future deaths.
Addressed to: HM Prison & Probation Service; Minister of State for Prisons, Parole and Probation