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 a lack of inpatient mental health beds, leading to delayed admission. Concerns were also raised about delays in Care Programme Approach appointments and excessive Care Co-ordinator caseloads, which impact risk assessment and patient support.
Addressed to: Birmingham Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner identified concerns regarding the ease of access to the external barrier wall of the car park, where the crash barrier can be used as a step. Additionally, there are few and poorly visible Samaritans signs.
Addressed to: Bedford Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a barrier in a short stretch of a dual carriageway's central reservation, which, if present, could deter pedestrians from using it as a shortcut despite nearby crossings.
Addressed to: Bristol City Council
AI-generated concerns summaryThe coroner noted the absence of a defibrillator at Hull Combined Court Centre, despite expert evidence on its importance for patient survival in cases of shockable cardiac dysrhythmia.
Addressed to: HM Courts and Tribunals Services; The Hull Combined Court Centre, Lowgate, Kingston upon Hull
AI-generated concerns summaryThe coroner identified a lack of clear, written protocols or pathways for the treatment and urgent referral of aortic aneurysms in the North West, noting confusion with hospital names and the absence of clear guidance for healthcare professionals.
Addressed to: Liverpool Heart and Chest Hospital NHS Foundation Trust; Lancashire Teaching Hospitals NHS Foundation Trust; Manchester University NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe hospital's central venous catheter removal policy and updated guidance were insufficient as they did not require constant visual observation, risking significant blood loss between intermittent checks. There is also an absence of national guidelines for central venous catheter removal.
Addressed to: British Renal Society, EBS Ltd.; Intensive Care Society; The Renal Association; Salford Royal NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified the lack of a structured health screening programme for Grenfell Tower survivors, first responders, and site workers exposed to smoke, dust, and potential asbestos. Concerns were raised about illnesses going unnoticed and the need for comprehensive mental health support.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the lack of specific warnings or advice from the FCO for travellers participating in tribal ceremonies involving Yage in Columbia, preventing them from making informed decisions.
Addressed to: FCO
AI-generated concerns summaryA senior clinician's advice on medication duration was not followed and was not transferred to electronic patient notes. This created a gap as junior doctors, who are not expected to consult handwritten records for prescribing, consequently missed critical information.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted inadequate anti-trespass measures at platform ends, including missing yellow paint and unreplaced signage. Concerns were also raised regarding gaps in mid-section fencing and the absence of gates at platform access points, alongside unreviewed Samaritan signage.
Addressed to: London North Western Railways
AI-generated concerns summaryThe coroner noted concerns that the pre-event risk assessment did not adequately identify risks at a minor junction, overlooking the potential for severe injury to fast-moving cyclists. A review of risk assessment methods for future events was suggested.
Addressed to: Human Race Limited
AI-generated concerns summaryThe coroner noted the risks of amitriptyline toxicity and raised concerns about a self-certification process for medication access that allowed inaccurate answers, especially when the patient's GP was not informed.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted insufficient CT imaging resources, including consultant and scanner availability, to manage simultaneous emergencies, which resulted in reporting delays. There was also no internal major incident policy for the radiology department.
Addressed to: Plymouth Hospitals NHS Trust
AI-generated concerns summaryA prisoner with a known history of serious self-harm was given access to razor blades. The coroner recommended developing protocols to deny razor blade access to prisoners known to have previously self-harmed using them.
Addressed to: HMP Elmley; THE SECRETARY OF STATE FOR JUSTICE
AI-generated concerns summaryThe coroner identified unsafe levels of nursing and medical staff due to funding models based on 85% occupancy, leading to insufficient numbers when the unit was full. Additional funding is needed to ensure appropriate staffing for the very sick babies.
Addressed to: Birmingham Woman’s and Children NHS Trust; CRG Lead Commissioner
AI-generated concerns summaryThe coroner identified issues with insufficient information sharing and accessibility between care services regarding a patient's recent contacts, leading to an incomplete picture for response officers and potentially affecting assessment and management.
Addressed to: London Borough of Camden
AI-generated concerns summaryThe coroner noted that midwives still advise side-by-side breastfeeding in bed, which can lead to inadvertent co-sleeping and death, particularly with fatigued mothers. Additionally, standard Trust documentation was not properly completed, omitting vital patient information and recorded advice.
Addressed to: Royal Bolton Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that the Rochdale Community Mental Health Team discharged the patient instead of transferring him to the Stoke team upon his move, and did not consult with alcohol advisory services as required.
Addressed to: Pennine Care HNS Foundation Trust; Rochdale Community Mental Health Team; Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the railway track is easily accessible to the public from Sandecotes Road bridge, with evidence of use by schoolchildren and others. There are also no warnings about the dangers of accessing this area.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted an underestimation of ambulance demand and insufficient ambulances, exacerbated by unrealistic A&E turnaround times leading to significant delays. Concerns were also raised about the unreliable system for welfare calls and the lack of engagement with police for welfare checks.
Addressed to: Cardiff and Vale University Health Board; Minister for Health; Welsh Ambulance Service Trust