Browse 6,470 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 summaryThere was no national policy for sharing information about prisoners receiving psycho-social support for substance misuse during transfers between prisons, leading to a gap in continuity of care.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a risk of falls from a specific location due to its relatively low wall and height, which could result in death. It was noted that this location might be sought out by others with suicidal thoughts.
Addressed to: Chesterfield Borough Council
AI-generated concerns summaryThe coroner noted no opportunity for pursuing drivers to communicate dynamic risk assessments to control centres and that drivers had too many tasks, leading to missed critical information. It was also stated that pursuits would be safer with a double-manned crew.
Addressed to: Home Office; South Wales Police
AI-generated concerns summaryThe coroner identified a lack of unified leadership and governance at Castlegate & Derwent Practice, alongside an absence of a robust method for investigating incidents.
Addressed to: Castlegate & Derwent Surgery
AI-generated concerns summaryHealthcare staff at HMP Chelmsford experienced difficulties navigating System One records to find previous self-harm incidents, potentially due to insufficient awareness of the importance of searching these records and inadequate training.
Addressed to: HCRG Care Group
AI-generated concerns summaryAccess to the steps is difficult as the handrail is too low and does not extend high enough for individuals to steady themselves before descending.
Addressed to: Landlord
AI-generated concerns summaryThe coroner raises concerns that hospital records lacked key detail regarding observations and the rationale for clinical decision-making, which could adversely impact the care of future patients.
Addressed to: West Suffolk Hospitals
AI-generated concerns summaryAn unprotected fire escape at a rehabilitation unit allowed easy access to the roof from the garden, with no environmental risk assessment completed for this structural vulnerability. The coroner noted a lack of guidelines for fire escape protections in rehabilitation settings.
Addressed to: Birmingham and Solihull Integrated Care Service; Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner noted the availability of online information for constructing certain items and that possession of materials for these items is not a criminal offence, creating a risk until proposed legislation is enacted.
Addressed to: Department of Health and Social Care; Home Department
AI-generated concerns summaryThe coroner identified a lack of a system to ensure important healthcare information, including medication details and physical observations, is passed between different healthcare providers in the criminal justice system during transfers. There is also no standard medical records system accessible by all providers for efficient information transfer.
Addressed to: IPRS Aeromed; Mitie; NHS England; Practice Plus Group
AI-generated concerns summaryThe coroner raises concerns about the Liaison and Diversion Team at Northampton no longer operating a Saturday Court Service, previously covered by an 'On Call' service, noting this absence could risk future deaths.
Addressed to: Northamptonshire Healthcare Foundation Trust
AI-generated concerns summaryThe coroner identifies insufficient discussion of SUDEP risks with epilepsy patients, citing doctors' reluctance, a presumption of prior conversations, and a lack of universal tools. SUDEP also being absent from medical training contributes to gaps in patient awareness.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryDevon and Cornwall Police recorded information about Mr. Fowkes's suicidal state but did not share this crucial risk assessment with West Midlands Police, who were only aware of drink driving and domestic abuse allegations.
Addressed to: Devon & Cornwall Police
AI-generated concerns summaryThe coroner noted the absence of specific questions in emergency dispatch protocols for tracheostomy patients experiencing breathing difficulties, particularly regarding the availability of suction equipment and trained personnel, which could prompt a Category 1 response.
Addressed to: International Academies of Emergency Dispatch
AI-generated concerns summaryThe coroner noted inadequate welfare checks and documentation by security officers, identifying a lack of staff training on how to conduct and record these checks. This raised concerns about residents potentially not receiving timely medical care.
Addressed to: MJ Events; Monmouthshire County Council
AI-generated concerns summaryThe coroner raised concerns about the lack of mandatory and sustainable training for clinical staff on automated CSF drainage systems, noting only 55% of relevant staff were trained with no clear plan for future staff in a high-rotation department.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the DVLA's reliance on drivers to self-report medical conditions affecting their fitness to drive. This approach allows some impaired drivers to continue driving due to dishonesty or lack of insight, risking future deaths among lawful road users.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified insufficient face-to-face contact by the care coordinator, partly due to referral issues causing patients to be assigned distant CMHTs. Concerns were also raised about inadequate risk assessment training and auditing, leading to non-compliance with policy.
Addressed to: Hampshire and Isle of Wight Healthcare
AI-generated concerns summaryThe coroner noted the hotel room's door locks were easily disengaged from inside and lacked secondary security. There was no physical barrier around the pool to prevent unsupervised access by children, and parents were not informed about room security features.
Addressed to: Association of British Travel Agents; TUI UK
AI-generated concerns summaryThe coroner noted insufficient comprehensive, joined-up care for mental health patients due to poor information sharing between services like GPs and private counselling. Concerns were also raised that increased reliance on remote appointments may not meet all patient needs.
Addressed to: Department of Health and Social Care