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 summaryFire alarm system buzzers in prison wing offices were deliberately disabled or tampered with, leading to delayed fire detection. Additionally, there is no central oversight of alarm faults as wing panels do not link to the main control room.
Addressed to: His Majesty’s Prison & Probation Service; Crown Premises Fire & Safety Inspectorate; Governor HMP Stocken
AI-generated concerns summaryThe prison telephone system lacks automated capability to recognise high or unusual volumes of prisoner calls, which may lead to missed opportunities for staff to identify risk triggers and prevent suicide. The data is available but requires manual monitoring.
Addressed to: Minister of State for Prisons, Probation and Reducing Reoffending
AI-generated concerns summaryThe coroner noted no evidence of a sepsis screen being undertaken prior to Miss Wood's discharge from the Emergency Department.
Addressed to: Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a national shortage of British Sign Language (BSL) interpreters and BSL-proficient clinicians, impacting mental health support for Deaf patients, and noted the absence of statutory regulation for BSL interpreters.
Addressed to: Cabinet Office, 1 Horse Guards Road, London SW1A 2HQ; Minister of State for Education, Department of Education, Orchard House, 20 Great Smith St, London SW1P 3BT; Minister of State, Minister for Social Security and Disability, Department for Work and Pensions, Caxton House, Tothill Street, London SW1H 9NA; Secretary of State for Health and Social Care, 39 Victoria St London SW1H 0EU
AI-generated concerns summaryThe coroner noted the absence of an effective internal investigation following Mrs Smith's death, which could lead to missed learning opportunities. There was also a lack of additional staff training or guidance, risking similar incidents.
Addressed to: Chief Executive Officer, Harbour Healthcare Limited, Lodge House, Dodge Hill, Stockport, Cheshire SK4 1RD
AI-generated concerns summaryThe coroner noted limited communication between hospital and community dietetic teams, along with a lack of guidelines and monitoring for dietetic assessments, particularly concerning the adequacy of telephone versus face-to-face consultations. Shared care teams also faced difficulties in accessing each other's records.
Addressed to: Aneurin Bevan University Health Board; Velindre University Nhs Trust
AI-generated concerns summaryFrontline police officers experience difficulty accessing the Police National Database to check for a history of domestic abuse in other force areas, which limits proactive responses to domestic violence.
Addressed to: [REDACTED] Secretary of State for the Home Department
AI-generated concerns summaryThe coroner raises concerns about inadequate follow-up processes for patients diagnosed with Barrett's oesophagus, particularly in primary care, leading to a risk of developing oesophageal cancer due to missed surveillance. There is no recall system and no prompts for GPs to consider endoscopy or surveillance.
Addressed to: Digital Health & Care Wales; [REDACTED] Chief Executive of Digital Health & Care Wales; Minister for Health and Social Services of Wales, [REDACTED]
AI-generated concerns summaryThe Trust's governance arrangements did not identify this case for a patient safety investigation, with the Datix system, morbidity and mortality meetings, and PSIRF procedure noted as inadequate. Senior governance staff also demonstrate an insufficient understanding of NHS England guidance regarding triggers for patient safety investigations.
Addressed to: [REDACTED] , Chief Executive Officer, Barts Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of communication from the Metropolitan Police to the psychiatric trust regarding Jake's release from custody. Furthermore, the police review did not identify any performance shortcomings or evidence of subsequent remediation.
Addressed to: [REDACTED], The Commissioner of Police of the Metropolis
AI-generated concerns summaryConcerns included inadequate monitoring of 'safer cells,' specifically a known broken observation panel that was not rectified as a ligature risk. The report also noted insufficient communication of risk during handovers and inconsistent performance of required observations for vulnerable prisoners.
Addressed to: Governor [REDACTED], HM Chief Inspector of Prisons [REDACTED], CEO of HMPPS [REDACTED]
AI-generated concerns summaryThe JAMES maintenance system lacks clear terminology, sufficient data extraction for governance, and a searchable database for recurring issues. Furthermore, there are no formal processes for inspecting, auditing, or providing real-time feedback on MOD vehicle repairs.
Addressed to: Secretary of State for Defence
AI-generated concerns summaryThe coroner identified a continuing risk to patient safety from misidentification due to staff not checking identity, inconsistent use of transfer checklists, and delays in communicating and investigating errors. Audits revealed ongoing non-compliance with patient identification processes.
Addressed to: York and Scarborough Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of legal requirements for servicing and maintaining agricultural tractors not covered by the Road Traffic Act 1988, which leaves their maintenance dependent on vehicle owners' discretion.
Addressed to: Department for Transport, Great Minster House 33 Horseferry Road London SW1P 4DR
AI-generated concerns summaryThe coroner identified insufficient staff training and understanding of guidelines for assessing sick children, including the use of physiological scoring systems. Concerns were also raised about limited senior clinical audit and monitoring of operational staff.
Addressed to: Chief Executive, East Midlands Ambulance Service NHS Trust (‘EMAS’)
AI-generated concerns summaryThe coroner noted insufficient information sharing of a positive bacterial swab result from an infected pacemaker wound with the surgical team, which may have delayed necessary pacemaker extraction at the earliest opportunity.
Addressed to: Lancashire Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryA lack of information sharing between specialist surgical extraction teams and local treating hospitals regarding the need for pacemaker extraction risks delayed or missed referrals.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryThe GP practice lacks a system or policy for appropriate medication reviews, frequency, and volume of repeat prescriptions for vulnerable patients with a history of addiction or self-harm, raising the risk of stockpiling and potential misuse.
Addressed to: Addison House Surgery
AI-generated concerns summaryConcerns were raised regarding the reliability of the nhs.net email system, where important mental health information was not received by a GP practice. This highlighted a need for improved communication processes between mental health services and primary care.
Addressed to: NHS England; Oxford Health NHS Foundation Trust; White Horse Medical Practice
AI-generated concerns summaryThe coroner raises concerns about the lack of oversight regarding food delivery licences being rented to children under 18, which places them in vulnerable positions involving lone working at night and increased risk of road traffic collisions.
Addressed to: Deliveroo; Home Office; Just Eats; Uber Eats