Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted that not all old prison wings have anti-barricade doors, which can delay staff access during emergencies. Concerns were also raised that Mr Molyneux was not on an ACCT plan despite expressing threats of self-harm.
Addressed to: HM Prison & Probation Service
AI-generated concerns summaryThe coroner noted that psychological therapies for Emotionally Unstable Personality Disorder (EUPD) had not been commissioned for the deceased despite her extensive history.
Addressed to: Department for Health; NHS England
AI-generated concerns summaryThe coroner noted delays in the deceased's ability to discuss antidepressant medication with a GP and concerns about his discharge from the community mental health team after a single consultation without a follow-up plan, despite prior suicide attempts.
Addressed to: Peel Medical Practice; South Staffordshire and Shropshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted an absence of mandatory requirements for child participants in a Hunt, including the use of personal protective equipment, demonstration of competence, and adult supervision with a stipulated ratio.
Addressed to: Cotswold Hunt; Council of Hunting; the Masters of Foxhounds Association
AI-generated concerns summaryThe coroner noted insufficient investigation by Wiltshire Council into a safeguarding referral regarding possible financial abuse. Additionally, Great Western Hospital's discharge summary did not include critical information about a patient's failed cognitive assessment.
Addressed to: Chippenham Community Hospital; Great Western NHS Hospital Trust; Wiltshire Health & Care; Wiltshire Council
AI-generated concerns summaryThe coroner noted the absence of Automated Electronic Defibrillators (AEDs) on the Metrolink tram network and at its stops, observing there is no legal requirement or industry standard for AED provision across UK tram networks.
Addressed to: Department for Transport; Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns about ongoing ambulance and Emergency Department delays, along with issues in resource availability and patient flow, noting these problems persist despite previous reports and continue to place patients' lives at risk.
Addressed to: Betsi Cadwaladr University Health Board; HM Stanley Site; Welsh Ambulance Services NHS Trust; Ysbyty Gwynedd
AI-generated concerns summaryA vulnerable, partially sighted passenger with dementia was able to disembark a train unsupervised at an intermediate station, subsequently accessing railway tracks and being struck by trains.
Addressed to: Network Rail; South Eastern Railways
AI-generated concerns summaryThe coroner raised concerns about the lack of effective follow-up by social services and housing, an inadequate response to a safeguarding alert, and the absence of a serious incident review following the death.
Addressed to: Milton Keynes Council
AI-generated concerns summaryThe coroner is concerned about insufficient funding for mental health services, particularly for the Early Intervention in Psychosis (EIP) team, leading to a shortage of doctors. This results in significant workload and waiting list issues, with concerns remaining regarding funding for additional medics.
Addressed to: Nottingham Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that neuroradiological reviews missed obvious signs of rising intracranial pressure on CT scans, and a critical report was not available for a key neurosurgeon consultation. There was also a lack of a Serious Incident Report for a preventable death.
Addressed to: Barking, Havering and Redbridge NHS Trust; Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the identification and escalation of care for acutely physically unwell patients in acute mental health settings. There was insufficient regular monitoring of vital signs, and established observation systems like NEWS were not always followed.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of formal guidance on safe tolerances and torque levels for two-post lifts, inadequate recording of these measurements during examinations, and insufficient operator training. Concerns were also raised regarding the safety of using foreign objects to provide vehicle clearance.
Addressed to: Garage Equipment Association; Health and Safety Executive; HSB Engineering Insurance Services Limited; Liftmaster Ltd; Minister of State for Disabled People, Health and Work; Safety Assessment Federation; West End Garage
AI-generated concerns summaryThe coroner noted the need for a system to implement discharge procedures within days rather than weeks, and recommended that the Hospital Trust and Clinical Commissioning Group consider a local protocol.
Addressed to: Clinical Commissioning Group for Milton Keynes; Milton Keynes University Hospital
AI-generated concerns summaryThe coroner identified ongoing, substantial delays in emergency department patient handovers, hospital admissions, and patient flow, frequently due to staff shortages and bed unavailability. These persistent issues reportedly place patients' lives at risk and prevent timely diagnosis and treatment.
Addressed to: Betsi Cadwaladr University Health Board; Conway County Council; Denbighshire County Council; Flintshire County Council; National Assembly for Wales; Welsh Ambulance Services NHS Trust; Wrexham County Borough Council
AI-generated concerns summaryThe coroner noted multiple fatalities and accidental injuries linked to Bio Ethanol burners, highlighting previous incidents in other areas including Uttoxeter and Staffordshire.
Addressed to: Chief Fire Officer’s Association
AI-generated concerns summaryConcerns were raised regarding Bio Ethanol burners, which have been linked to at least a second fatality in the area, alongside previous deaths and numerous accidental injuries reported nationally.
Addressed to: Chief Fire Officer’s Association
AI-generated concerns summaryThe coroner identified a lack of secondary care access to GP records, such as a patient's haemophilia diagnosis, which risks future deaths if critical medical information is unavailable.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns that future deaths may occur unless Novel Psychoactive Substances (NPS) can be more accurately analysed and detected by toxicological testing, highlighting a lack of specific evidence presented at the inquest regarding steps to address this risk.
Addressed to: Pharmaceutical Chemistry, Drug Misuse and Novel Psychoactive Substance Unit, University of Hertfordshire
AI-generated concerns summaryThe coroner identified concerns regarding the continuity and appropriateness of medical staff dispatched by Hawthorn Medical Practice GPs, and questioned the implementation status of recommendations from a November 2015 safeguarding report.
Addressed to: Lincolnshire Community Health Service NHS Trust; Lincolnshire Register Office