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 confusion over a risk assessment question for in-possession medication, potentially leading to incorrect authorisations. Further concerns included unreliable 'read coding' in prison healthcare records and insufficient healthcare attendance at ACCT reviews.
Addressed to: Birmingham and Solihull Mental Health NHS Trust; Birmingham Community NHS Trust; G4S; MOJ; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a multi-agency preventative approach to assess and manage risks from a social housing tenant's behaviours linked to his serious mental illness, including insufficient documentation of these risks in mental health care plans and clinical notes.
Addressed to: SW Yorks NHS Trust; Together Housing; West Yorkshire Fire and Rescue Service
AI-generated concerns summaryThe coroner identified gaps in integrated care for patients with co-occurring mental health and substance misuse issues, leading to inadequate support. Insufficient communication and feedback between addiction services and the GP, alongside unaddressed consent for disclosure, compromised ongoing care.
Addressed to: Addaction; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted the absence of immediate and effective alert systems at railway stations for persons on the line, as well as alternative detection methods to trigger appropriate responses.
Addressed to: Northern Rail Limited
AI-generated concerns summaryThe coroner noted the withdrawal of funding for MIND's counselling services by the Council and CCG, raising concerns that this decision could lead to further deaths from suicide among vulnerable individuals.
Addressed to: Milton Keynes Clinical Commissioning Group; Milton Keynes Council
AI-generated concerns summaryThe coroner identified inadequate communication between the Trust and GP advising on the urgent removal of a pessary. Concerns were also raised regarding insufficient follow-up, routine cleansing, and monitoring of vaginal integrity during pessary use.
Addressed to: Oaks Medical Centre; Sandwell and West Birmingham NHS Trust
AI-generated concerns summaryThe coroner identified that ambulance doors cannot be locked when stationary, which may affect police containment of individuals escorted under Section 136 of the Mental Health Act.
Addressed to: Dyfed-Powys Police; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner identified a need for clarification on how to interpret the "whenever possible" proviso in PSI64/2011 concerning ACCT first case reviews. Consideration should be given to re-drafting this part of the PSI and providing guidance on its practical application by prison staff.
Addressed to: HM Inspector of Prisons; Independent Advisory Panel on Deaths in Custody; National Offender Management Service
AI-generated concerns summaryThe coroner noted a lack of safe crossing points for pedestrians, including school children, at a busy junction. Concerns were also raised about the absence of barriers between the road and pavement and inadequate accommodation for cyclists, such as dedicated lanes or advanced stop lines.
Addressed to: Dorset Highways Department
AI-generated concerns summaryThe report indicates a risk of future deaths, but specific concerns are not detailed in the provided text.
Addressed to: Medico Legal Manager; Sussex NHS Trust
AI-generated concerns summaryInadequate care plans and insufficient review processes, coupled with incomplete daily observation and clinical records, were identified. Concerns also included insufficient trained staff, non-adherence to medical referral protocols, and inadequate staff supervision and governance.
Addressed to: Zinnia Healthcare Limited
AI-generated concerns summaryThe coroner noted that private hospitals' NEWS policies for critically unwell patients may not align with emergency response guidance due to consultant availability. Also, general ward nursing staff may lack adequate training for complex post-operative care.
Addressed to: Independent Healthcare Providers Network; Ramsay Healthcare UK
AI-generated concerns summaryThe coroner noted that a falls risk assessment was not followed at Rosehill House Care Home, meaning a resident lacked assistance and supervision when mobilising and experienced multiple falls. There is a need for regular falls risk assessments and adherence to care plans.
Addressed to: Rosehill House Care Home
AI-generated concerns summaryThe coroner noted concerns that the time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital may place lives at risk.
Addressed to: Ministry of Health; MOJ; NHS England
AI-generated concerns summaryLate transfers of prisoners, particularly on weekends, increase risk due to inadequate mental health assessments, reduced healthcare staffing, and limited access to medical records. There is no national guidance for these transfers.
Addressed to: MOJ; NHS England
AI-generated concerns summaryThe coroner identified a lack of street lighting in the area where a road collision occurred, particularly near bus stops and a popular wedding venue. They recommended consideration be given to erecting street lighting in this specific area.
Addressed to: North Yorkshire County Council
AI-generated concerns summaryThe coroner raises concerns about the safety aspects of a pathway running along a steep embankment overlooking a river and requests a review of the appropriateness of fencing in that area.
Addressed to: Midgehole Working Mens Club
AI-generated concerns summaryThe coroner highlighted a need to review GP referral practices to schools for CAMHS consideration and improve communication between health and education professionals to eliminate contradictory advice. Additionally, the report called for consideration of fast-tracking preventative measures at North Bridge, Halifax.
Addressed to: Calderdale Council; Department of Health and Social Care; NHS Calderdale Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified a lack of policy for additional checks on prisoners with repeat NPS use, especially when combined with existing medical conditions. There was also no method for drug workers to communicate these risk factors to healthcare or prison officers, and drug workers lacked access to medical records to …
Addressed to: Forward Trust; HMP Stoke; Shropshire Community Health NHS Trust
AI-generated concerns summaryThe coroner raised concerns about insufficient refresher training for an emergency response driver, police under-resourcing, and inadequate terminology used to convey the urgency of situations.
Addressed to: Metropolitan Police