Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryInsufficient inquiry into a prior incident limited the RAF's suicide risk assessment for Mr Bunton. The coroner also noted weaknesses in the clinical care review process and significant delays in evidence gathering for subsequent investigations.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted insufficient action from the Trust to prevent recurrence of doctors failing to document Nil by Mouth (NBM) advice and ensure timely Speech & Language Therapy (SALT) referrals, nearly 12 months after these issues were identified.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner notes a lack of proactive public communication regarding the 'Right Care Right Person' policy, which could lead to delays in the public seeking emergency assistance for family members.
Addressed to: College of Policing; RCRP Strategic Partnership Board
AI-generated concerns summaryThe psychiatric liaison team's assessment did not sufficiently recognise the deceased's acute mental health deterioration and suicidal ideation, and there was no risk assessment documentation or escalation to a doctor.
Addressed to: South London and Maudsley NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the lack of clear procedures for care home staff regarding medication recording and administration when a patient returns from hospital without a discharge letter. This led to incorrect medication being given and an opioid overdose.
Addressed to: Care UK
AI-generated concerns summaryCoroner noted lack of Emergency Department review for atypical aortic dissection meant learning was missed. A middle-grade doctor did not escalate patient change, suggesting related training was ineffective.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe Trust did not investigate two unwitnessed falls sustained by a patient during a hospital admission under the Patient Safety Framework, raising concerns about its ability to identify and address sub-optimal practices. Evidence of remediation provided by the Trust was vague.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that stewards did not know the location of staff with radios, which could lead to future delays in summoning medical assistance and raise a risk of future deaths.
Addressed to: Sheffield Wednesday Football Club
AI-generated concerns summaryThe coroner noted a lack of available inpatient mental health beds for high-risk individuals who cannot be safely managed in the community. This resulted in community teams managing unmanageable risk, contributing to preventable deaths.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified that Community Mental Health Teams lack mandatory training on perinatal red flags, and the expert Perinatal Team is not commissioned for urgent visits. Concerns were also raised about insufficient professional curiosity and communication with family by mental health professionals.
Addressed to: Hampshire and Isle of Wight Healthcare
AI-generated concerns summaryThe coroner raised concerns regarding an expired and potentially unclear Standard Operating Procedure for alcohol dependence, and noted chaotic emergency care delivery, including faulty equipment and inadequate CPR training.
Addressed to: Practice Plus Group
AI-generated concerns summaryThe coroner noted insufficient information sharing between professionals, incomplete care plans and risk assessments before discharge, and an inappropriate care home placement for a complex mental health patient. Visiting professionals did not complete required reviews during crises.
Addressed to: Essex County Council; Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about vulnerable individuals, including children in mental health crisis, accessing online material that reinforced a decision to end their life. Challenges in obtaining online data from service providers outside UK jurisdiction were also noted.
Addressed to: Google UK & Ireland
AI-generated concerns summaryA nurse lacked mandatory life support training, a recurring issue, and the Trust has no system for contemporaneous digital recording of patient observations on wards, raising concerns about accurate timing and trend analysis.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inaccuracies in fluid balance charts, issues with seizure activity assessment in the Emergency Department unless witnessed, and a lack of procedures for ED staff to consider recent surgery or contact original treating departments for readmitted patients.
Addressed to: East Lancashire NHS Trust
AI-generated concerns summaryThe coroner noted insufficient documentation for positional changes to prevent pressure damage, a lack of evidence regarding training for agency nurses, and inadequate wound care training. Concerns were also raised about ongoing substandard documentation practices.
Addressed to: Malhorta Group; Prestwick Care
AI-generated concerns summaryThe West Yorkshire Police first aid training was inadequate, especially regarding assessment of normal breathing and responsiveness. Operational officers also lacked knowledge and promotion of the 'Partner Triage Line' medical advice service.
Addressed to: National College of Policing; National Police Chiefs Council
AI-generated concerns summaryThe coroner noted insufficient staff introductions and inconsistent information sharing between ambulance services and the MIU. Concerns were also raised about an incomplete assessment for a patient with dementia, due to the exclusion of a family member and a nurse clinician's assumptions.
Addressed to: Cornwall Partnership Foundation Trust; Lifestar Medical Limited; South West Ambulance Service Trust
AI-generated concerns summaryAbnormal findings on three separate CT scans were not reported by reviewing radiologists. Additionally, Barking Havering & Redbridge NHS Trust does not have a peer review system for radiology cases, as recommended by the Royal College of Radiologists.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryInadequate documentation of consent discussions and insufficient explanation of risks regarding an NG tube were identified. The coroner noted non-compliance with existing policies and an absence of clear professional responsibility for ensuring crucial care explanations.
Addressed to: Association of Anaesthetists; Milton Keynes University Hospital; Royal College of Anaesthetists; Royal College of Surgeons