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 easy pedestrian access to the A40 near Monmouth and the lack of signage to alert pedestrians or prevent them from entering the slip road, despite this not contributing to the specific death.
Addressed to: Monmouth County Council
AI-generated concerns summaryThe coroner raises concerns regarding the appropriateness of the client wellbeing checks protocol, specifically concerning physical checks during sleep, after drug use, and the need to rouse clients to confirm their wellbeing.
Addressed to: Oasis Recovery Communites; Treatment Direct Limited
AI-generated concerns summaryConcerns were raised that ACCT observations were not conducted but recorded as completed. The coroner also noted officers' insufficient understanding of ACCT procedures and inadequate training, requiring refresher courses to safeguard vulnerable prisoners.
Addressed to: Advisory Panel on Deaths in Custody; HM Inspector of Prisons; HMP Lindholme; National Offender Management Service; Prison Officers Association; The Chief Coroner
AI-generated concerns summaryThe coroner noted an over-emphasis on prisoner assertions of no self-harm intent, insufficient consideration of all risk factors during assessments, and a lack of written records detailing how self-harm and suicide risk assessments were conducted.
Addressed to: Greater Manchester mental Health NHS Trust; HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted the absence of mental health support signage at Culver Cliff, a location where individuals in mental distress are frequently found. Despite recommendations from police and psychiatrists, these signs have not been reinstated.
Addressed to: Isle of Wight Council; National Trust on the Isle of Wight
AI-generated concerns summaryThe coroner raised concerns that vulnerable 16-18 year olds are placed in unregulated settings, which lack statutory inspection and regulatory compliance. This means staff competency and adequate policies are not consistently verified, placing an impractical burden on local authorities for oversight.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted the absence of a licensed antidote for Edoxaban and insufficient sharing of associated bleeding risks with non-tertiary centres. Concerns also included a lack of national guidance for antidote administration target times and storage.
Addressed to: Department of Health and Social Care; Greater Manchester Mental Health and Social Care; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted the absence of reasonable adjustment care plans in emergency settings and a lack of formal best interests meetings for key decisions. Concerns were also raised about insufficient inter-agency communication and the limited availability of acute learning disability beds.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified concerns regarding an on-call consultant's apparent lack of confidence to perform emergency hysterectomy without a second consultant, insufficient professional curiosity about the cause of DIC, and a lack of leadership in patient care. This may place pregnant women requiring emergency surgery at risk.
Addressed to: GMC; James Paget University Hospital NHS Trust
AI-generated concerns summaryThe coroner identified a delay in seeking medical attention for Keith on 8th September and a lack of timely communication with family members regarding his fall.
Addressed to: Hunters Lodge Care Home
AI-generated concerns summaryThe coroner noted failures by GMMH to expedite the search for and secure an inpatient mental health bed, citing insufficient communication and information exchange with PCFT, and decisions to abandon the search without clinical input.
Addressed to: Manchester Mental Health NHS Trust; Pennine Care Mental Health Trust
AI-generated concerns summaryThe coroner identified a lack of family involvement and communication regarding the decision to remove a patient from a Mental Health Act section. There was no formal policy for informing families or inviting them to MDT meetings, leading to confusion among staff regarding responsibilities.
Addressed to: TRU
AI-generated concerns summaryThe coroner noted concerns regarding the misplacement of a nasogastric tube twice in the same patient, which resulted in pneumothorax and contributed to death.
Addressed to: Warwick Hospital
AI-generated concerns summaryInadequate hourly monitoring of patient observations occurred due to nurse understaffing, as levels were below the template. The Serious Incident Report did not detail the Trust's plans to resolve understaffing issues or address care omissions.
Addressed to: Blackpool Victoria Hospital
AI-generated concerns summaryThe coroner identified a lack of communication between medical specialists and inadequate medical record-keeping for changes in treatment plans and medication decisions. Concerns were also raised about insufficient support for junior medical staff and the lack of specialist pharmacy guidance out-of-hours.
Addressed to: Barts Health
AI-generated concerns summaryA doctor prescribed morphine without knowing the dose already given by paramedics. The coroner identified a risk arising from the differing units of measurement for opiate medication used by pre-hospital and hospital services.
Addressed to: Barking, Havering & Redbridge University Hospitals NHS Trust; London Ambulance Service
AI-generated concerns summaryThe coroner noted paramedics did not pre-alert the emergency department about a patient with suspected sepsis, a discretion incompatible with JRCALC guidelines. Concerns were also raised about paramedics' inability to administer intravenous antibiotics for sepsis in an ambulance, increasing mortality risk during hospital admission delays.
Addressed to: Welsh Ambulance Service NHS Trust
AI-generated concerns summaryLack of referral for genetic investigation for a child with multiple conditions, despite parental requests, meant an underlying serious cardiomyopathy went undiagnosed, contributing to her death during a general anaesthetic.
Addressed to: Torbay and South Devon NHS Trust; University Hospitals Bristol
AI-generated concerns summaryThe coroner noted ineffective management of patient records and poor cross-department communication at RSCH, exacerbated by multiple incompatible software systems and paper records without mandatory usage rules or quality assurance.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a need for clinical assessments for frail residents at Glebelands following falls and for any residents whose health deterioration was observed by staff.
Addressed to: Glebelands Care Team