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 summaryMental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.
Addressed to: Brighton and Hove City Council; Sussex Partnership Foundation NHS Trust
AI-generated concerns summaryThe coroner identified gaps in risk assessments for virtual mental health appointments during the pandemic, including the absence of a plan for urgent patient review. Concerns also included outdated care plans and a failure to share critical risk information with the patient's family.
Addressed to: Ministry of Defence; Woolwich Station Medical Centre
AI-generated concerns summaryThe coroner noted concerns that a website may be promoting a method of suicide, potentially assisting suicide, and that a lethal substance is freely available online, sold as a meat preservative.
Addressed to: Department of Health and Social Care; eBay UK Ltd; Metalchem Ltd
AI-generated concerns summaryThe BAPM guidance on neonatal central venous catheters omits a key mal-positioning risk factor, and there is no NICE guidance or requirement for NHS Trusts to ensure staff familiarity or policy compliance with BAPM recommendations.
Addressed to: British Association of Perinatal Medicine; NHS England
AI-generated concerns summaryThe coroner noted a lack of signage to discourage pedestrians from walking on the A66. Concerns were also raised about the speed of traffic and poor lighting on an initial stretch of the A66, exacerbated by the national speed limit sign's proximity to a roundabout.
Addressed to: Highways England Co. Ltd and Cumbria County Council (Highways)
AI-generated concerns summaryThe coroner noted staff shortages led to a patient being kept overnight in an unsuitable area. An outstanding request for increased staffing for the unit has not been addressed by the Trust.
Addressed to: Maidstone and Tunbridge Wells NHS Foundation Trust
AI-generated concerns summaryThe coroner noted deficiencies in police procedures for domestic abuse cases, including the application of bail conditions and identification of serious perpetrators. There were also concerns regarding insufficient officer training on risk assessment and information sharing with the CPS.
Addressed to: Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, Crown Prosecution Service, Greater Manchester Health and Social Care Partnership, Home Office and Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the absence of parking restrictions and a requirement for signage on a stretch of the A20 Ashford Road, leading to large vehicles stopping without warning for other road users.
Addressed to: Highways Department Kent County Council and TARMAC A CRH Company
AI-generated concerns summaryThe coroner raised concerns about the potential loss of funding for peer support workers in March 2021, highlighting their invaluable support and unique lived experience in assisting individuals with mental health and substance misuse issues.
Addressed to: Blackpool Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified concerns that bed levers are being fitted and adjusted without the patient present, failing to consider individual factors, and not always by fully trained experts. Additionally, the report notes issues with Mobility 2000 regarding the supply of bed levers without straps for inappropriate bed types and unclear …
Addressed to: NHS England, Blackpool Teaching Hospitals, Lancashire County Council and Mobility 2000 Ltd
AI-generated concerns summaryThe coroner identified a need for improved communication regarding fire/smoke alarms designed for people with dementia and greater collaboration with support groups to promote their use.
Addressed to: Staffordshire Fire and Rescue Service HQ
AI-generated concerns summaryThe coroner noted that Staffordshire Fire and Rescue Service might benefit from awareness when domiciliary care recipients do not use provided special fire safety equipment, suggesting improved communication with care providers.
Addressed to: Staffordshire Fire and Rescue Service HQ
AI-generated concerns summaryThe coroner noted that children under 16, particularly boys, may not respond to conventional smoke alarms. This indicates a need for fire suppression systems to be legally required in all new-build properties in England.
Addressed to: Housing of Vulnerable People (Building Safety)
AI-generated concerns summaryThe coroner noted the absence of a joint policy and multi-agency structure for police and health professionals to share information regarding vulnerable missing persons with mental health difficulties, and a lack of mandatory refresher training for officers on mental health issues.
Addressed to: Northumbria Police, Newcastle City Council, St. Nicholas Hospital and House of Commons
AI-generated concerns summaryThe coroner noted insufficient communication between officers regarding Ms Bouasbia's expressed wish to end her life, and a risk assessment for self-harm was not completed. The police response to a text message indicating suicidal thoughts was limited.
Addressed to: Home Office; Metropolitan Police Service
AI-generated concerns summaryThe coroner noted incomplete patient records, difficulty contacting on-call medical staff, and a lack of communication with the GP regarding required post-discharge nutrition monitoring, leading to a gap in follow-up.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryInstructions for managing the NG tube were not clearly noted by the House Officer, and nursing staff, including agency staff without relevant training, lacked clinical guidance. Concerns about the NG tube's function were also not properly escalated to clinical staff.
Addressed to: Department of Health and Social Care; Royal London Hospital
AI-generated concerns summaryThe coroner noted concerns that hospital staff did not adequately consider mental health needs in falls risk assessments, and that specialist mental health provision to support staff in caring for such patients might be insufficient.
Addressed to: Barnsley Hospital NHS Foundation Trust
AI-generated concerns summaryThe university did not hold a face-to-face meeting with a student under 18 or contact their guardian/parents before emailing about potential course removal, and lacked a clear policy for these actions.
Addressed to: Coventry University
AI-generated concerns summaryThe coroner noted inadequate record-keeping for patient care and administered dosages, which made corroborating staff testimony difficult. Concerns were also raised that unused drugs were not accounted for, posing a risk to patient safety if care is unrecorded or duplicated.
Addressed to: Mid Yorkshire Hospitals NHS Trust