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 excessive reliance on self-declaration questionnaires for diving licence renewals without further medical inquiry, which led to a diver not disclosing a significant past cardiac event. This practice creates potential risks for divers and others.
Addressed to: British Sub Aqua Association; Sub Aqua Association Spcae Solutions Business Centre
AI-generated concerns summaryThe police did not pass next of kin details to the Section 136 suite, which prevented family contact and updates. Additionally, missing information on the PNC check and a force control email meant a recent Section 136 detention was not flagged, thus mental health services were not contacted for further …
Addressed to: South Yorkshire Police Headquaters
AI-generated concerns summaryThe coroner expressed concern that novel psychoactive substances and other contraband continue to enter HMP Birmingham, overwhelming current interception measures. This leads to a high burden on prison staff, as target staffing figures appear insufficient to manage 'spikes' in under-the-influence incidents.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted significant medication errors, including the non-administration of prescribed pain relief, incorrect dosage adjustments without patient review, and insufficient scrutiny by staff. Additionally, there were delays in escalating the patient's deterioration and initiating an emergency call despite a high NEWS score.
Addressed to: NHS England; Princess Aleandra Hospital
AI-generated concerns summaryThe coroner identified that the Older People’s Mental Health Service is not routinely informed of patients' Emergency Department admissions or discharges for physical health issues due to system access limitations. This information gap could delay essential follow-up and risk management.
Addressed to: Southern Health Foundation Trust
AI-generated concerns summaryThe coroner noted delayed recognition of Mr Morrell's heart failure and the absence of a standard operating procedure for HOCM patient referrals. A three-year gap in cardiac scans meant deterioration was not detected, potentially delaying earlier intervention.
Addressed to: York and Scarborough Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of universal guidance or safety netting policies from NHS England for the transfer of vulnerable mental health patients from secondary to primary care, which places the onus on patients to arrange follow-up at a vulnerable time.
Addressed to: [REDACTED], Chief Executive Officer, NHS England: [REDACTED]; [REDACTED], Parliamentary Under-Secretary for Patient Safety, Women’s Health and Mental Health, 39 Victoria Street, London SW1H 0EU
AI-generated concerns summaryThe coroner noted confusion among stroke clinicians regarding overnight stroke support, raising concerns that time-critical expert advice from a consultant might be delayed. In Mrs Crooks' case, advice was given by a registrar, and delays could affect patient outcomes.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryPoor documentation of care and risk made it difficult to ascertain what care was delivered. Falls risk assessments were incomplete and not updated, and the falls policy regarding medical advice for unwitnessed falls in patients on anticoagulation was not consistently understood or followed by staff.
Addressed to: Lakes Care Centre
AI-generated concerns summaryThe coroner identified poor patient handling, hygiene issues, and unsupervised medication administration. Concerns were also raised about insufficient pre-surgical blood test review and gaps in the systems for assessing transplant list suitability and communication between teams.
Addressed to: St George’s University Hospitals
AI-generated concerns summaryThe coroner raised concerns about drivers not self-notifying the DVLA of medical conditions affecting driving fitness, the clarity of advice given to drivers, and the awareness and effectiveness of guidance for medical professionals. Additionally, a national road safety strategy has not been published despite a 2023 call for evidence.
Addressed to: Department for Transport; DVLA; General Medical Council; General Optical Council
AI-generated concerns summaryThe coroner identified a gap in safe and supportive spaces for mental health patients not in immediate crisis. There is also a need for clearer national guidance on including family members and GPs in care plans, especially when they are key protective factors.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of holistic approach in discharge planning and insufficient communication with Mr. Gray's carers regarding his fluctuating delirium and potential for agitation. This meant they lacked critical information for his post-discharge care.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient processes for the timely prescription of usual medication for patients admitted late and unexpectedly. There was also a lack of clarity regarding which clinical role is responsible for preparing such prescriptions upon admission.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner raised concerns that software removed a patient's repeat prescription without GP notification or choice, which risks patients not receiving necessary medication, particularly for elderly individuals or those on multiple prescriptions.
Addressed to: Optum
AI-generated concerns summaryThe coroner raised concerns about the need for a lower threshold for hospital admission for patients with learning disabilities, requiring face-to-face doctor consultations. Post-consultation, written instructions including safety netting advice should be provided in an accessible format for non-medically trained staff.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryNo action was taken by the prison or healthcare after a prisoner on a drug-free wing tested positive for non-prescribed drugs. Pathways for positive test results were unclear or not followed, leading to a missed opportunity to support the individual.
Addressed to: HMP Wormwood Scrubs; Ministry of Justice; Practise Plus Group
AI-generated concerns summaryThe coroner noted the very substantial contribution of falls to the death of a resident with vascular dementia from bronchopneumonia.
Addressed to: SCAS Legal Services
AI-generated concerns summaryGaps in continuity of care due to different admitting teams across multiple hospital admissions led to delays in investigating Mrs Talbot's history of diarrhoea. The Trust has not fully assessed how its new record system can effectively ensure continuity of care in similar scenarios.
Addressed to: [REDACTED], Chief Executive Officer, King’s College Hospital NHS Trust, King’s College Hospital, Denmark Hill, London, SE5 9RS
AI-generated concerns summaryThe coroner noted an absence of speed enforcement on a stretch of the A3083 road where multiple fatal collisions have occurred, some attributed to excessive speed, and highlighted options for camera installation.
Addressed to: Service Director for Environment Cornwall Council