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 that Essex Police refused to investigate the supply of tablets to the deceased, despite a request from Northamptonshire Police regarding a suspect identified through the deceased's mobile phone.
Addressed to: Essex Police
AI-generated concerns summaryThe coroner identified ongoing staffing shortages, lack of infrastructure investment, and significant delays in endoscopy wait times for all referral categories. It was also noted that these concerns do not appear on the corporate risk register.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted recurrent failings at EPUT, previously identified in multiple PFD reports, concerning care planning, risk assessment, documentation, and internal communication. Actions taken to address these acknowledged issues have been inadequate.
Addressed to: Essex Partnership University NHS Foundation Trust; HCRG; HMPPS; MoJ
AI-generated concerns summaryThe coroner noted concerns regarding water flowing across the A1 carriageway for an extended period, which subsequently froze and created dangerous icy conditions that were not addressed. Concerns were also raised about the effectiveness of reporting mechanisms available to the public for such road hazards.
Addressed to: Lincolnshire County Council; Lincolnshire Police; National Highways Midlands region
AI-generated concerns summaryClinical staff at Avondale Unit were unable to access important mental health records from partner NHS institutions, which compromised the patient's assessment and subsequent management.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified varying national guidance for autism diagnosis, meaning Joshua was not formally diagnosed and missed specialist dietetic referral. Concerns were also raised about the Capillary Refill Time test being an insensitive measure for assessing dehydration in young children.
Addressed to: Birchill’s Health Centre; NHS England (Reg 28 Reports); Walsall Healthcare NHS Trust; Walsall Local Authority
AI-generated concerns summaryThe coroner noted that patients at high risk of self-harm could leave the acute ward without proper risk assessment or staff knowledge. There was also a lack of clarity in the Mental Health Liaison Service's criteria for escalating patients to a Consultant Psychiatrist, limiting oversight.
Addressed to: Essex Partnership University NHS Trust; Mid & South Essex NHS Foundation Trust
AI-generated concerns summaryThe report identified a lack of appropriate neurological investigation and structured observations, unreliable medical records, and delays in psychiatric input for discharged patients, particularly over bank holidays.
Addressed to: East Kent Hospitals University NHS Foundation Trust; Kent and Medway NHS and Social Care Partnership Trust
AI-generated concerns summaryThe coroner notes that a care agency team leader provided wound care despite clear instructions not to, raising concerns about inadequate training for carers on the limits of their care and adherence to specialist medical advice.
Addressed to: Ignite Health and Homecare Services
AI-generated concerns summaryThe coroner identified a lack of a national interface for communication between schools and safeguarding agencies, alongside an absence of national guidance for referrals, leading to inconsistent reporting practices.
Addressed to: Department for Education; Women and Equalities
AI-generated concerns summaryThe coroner noted gaps in national pathways for call handlers, highlighting the need for further guidance on probing questions regarding breathing and body temperature assessment, as well as techniques to confirm breathing and locate a pulse during emergency calls.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns regarding inadequate pain management, insufficient nutritional support leading to significant weight loss, and poor pressure sore care, which deteriorated to grade 4 and contributed to death.
Addressed to: East Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified a two-tiered system for assessing breathing complications, where 999 (MPDS) and 111 (NHS Pathways) triage can lead to different ambulance categorisations for similar urgent symptoms.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted the absence of Acute Behavioural Disturbance (ABD) protocols between police and ambulance services in Lincolnshire, contrary to recommendations. They also highlighted that ABD lacks its own allocation pathway within the NHS Pathways system, leading to lower response categories.
Addressed to: East Midlands Ambulance Service NHS Trust; Lincolnshire Police; NHS England
AI-generated concerns summaryThe coroner identifies a lack of specialist dietetic service at CGH outside of weekday working hours, which can delay feeding or result in incorrect care, raising the risk of avoidable future deaths.
Addressed to: East Suffolk and North Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues with the urgent care pathway for serious non-life-threatening illnesses, including unreliable information transfer between 111, EMAS and NEMS, lack of family notification, and unclear criteria for Category 3 call transfers.
Addressed to: East Midlands Ambulance Service NHS Trust; NHS England; Nottingham and Nottinghamshire Integrated Care Board; Nottingham Emergency Medical Service
AI-generated concerns summaryThe Nottinghamshire urgent care pathway poorly serves patients with serious systemic illness needing Category 3 ambulance responses. This is due to EMAS staff not reliably using 111 information and families not being informed of ambulance cancellations.
Addressed to: East Midlands Ambulance Service NHS Trust; NHS England; Nottingham and Nottinghamshire Integrated Care Board; Nottingham Emergency Medical Service
AI-generated concerns summaryThe mental health provider did not adequately address risks on discharge for an individual with violent paranoid schizophrenia and lacked insight. There was no multidisciplinary team plan for medication non-concordance, and support for other medication was withdrawn without checking GP compliance.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns that Ms Adams, who was prescribed sedative medication, was not given a specific warning about the risks of over-sedation when combining prescribed and non-prescribed medication. It was also unclear if such specific warnings were being implemented.
Addressed to: Northamptonshire Healthcare Foundation Trust
AI-generated concerns summaryThe coroner expressed concern about manufacturing voids and asymmetrical pins in porcelain tension disc insulators, which can lead to failure and create low hanging power lines, a risk previously unknown. Although technology now exists to detect these issues, it was not in use at the time.
Addressed to: Electricity Networks Association