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 summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS trauma treatment pathways, and no multi-agency meeting was called despite multiple agencies being involved.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient clarity on how carers' views inform patient safety plans and a lack of clear guidance for staff on using video evidence in decisions. Concerns were also raised about checks to ensure carers are equipped to support patients at home.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryThe absence of a policy for microbiological wound swabs during re-suturing potentially delayed infection detection and treatment, which could have prevented fatal staphylococcal meningitis.
Addressed to: Newcastle upon Tyne Hospitals NHS Foundation Trust
AI-generated concerns summaryWest Midlands Police had insufficient resources to allocate officers to priority cases, resulting in significant delays. This raises a risk of future deaths if resource levels are not sufficient to manage daily case numbers.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted concerns that the CIWA protocol is insufficiently nuanced for elderly or delirious patients, creating a risk of over-sedation. Additionally, current NICE guidelines on alcohol withdrawal do not explicitly cover this situation, which could recur and lead to future deaths.
Addressed to: National Institution for Health and Care Excellence
AI-generated concerns summaryThe coroner noted inadequate information for families and carers regarding how to share concerns and communicate information when a capacitous adult has withdrawn consent for information sharing, without breaching confidentiality requirements.
Addressed to: CGL (Ealing RISE)
AI-generated concerns summaryThe coroner noted insufficient follow-up on a recommended podiatrist referral and a lack of knowledge among nursing staff regarding the purpose of such referrals and the importance of adhering to Tissue Viability Nurse dressing recommendations.
Addressed to: Powys Teaching Hospital Board
AI-generated concerns summaryThe coroner notes that the 60mph speed limit is too high for the stretch of Sarratt Road between the M25 over-bridge and the speed restriction sign for Sarratt Village.
Addressed to: Chief Executive Hertfordshire County Council
AI-generated concerns summaryThe coroner noted a lack of a structured algorithm for non-medical call handlers to triage unwell clients and determine a course of action. There was also no ability for carers to conduct basic observations to monitor clients or provide a baseline for assessment.
Addressed to: Chief Executive, Care Quality Commission; Secretary of State for Health and Social Care, Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that a shortage of foster placements led to unsuitable child placements. Additionally, there were inadequate documentation, communication of risks, and formal risk assessments regarding foster carers and other children in their care.
Addressed to: Chief Executive, Rotherham Metropolitan Borough Council; Secretary of State for Education, Department for Education
AI-generated concerns summaryThe coroner identified differing interpretations and training among police forces regarding 'spontaneous pursuits' guidance. Concerns were also raised about the absence of a full forensic collision investigation report during a conduct investigation by the IOPC into a fatal incident.
Addressed to: IOPC; College of Policing
AI-generated concerns summaryThe coroner noted a lack of first aid-trained staff and managers at Tesco, which led to inadequate recognition and response during a medical emergency, including failure to perform CPR or use a defibrillator.
Addressed to: Chief Executive Security Industry Authority (SIA); Chief Executive Tesco PLC; Chief Executive Total Security Services Limited (TSS)
AI-generated concerns summaryA significant risk of future delays in crucial diagnostic tests was identified due to the lack of a formal pathway or referral process for escalating cases where a lumbar puncture is needed but cannot be performed by ward doctors.
Addressed to: CEO, Stockport NHS Foundation Trust
AI-generated concerns summaryConcerns included insufficient staff training for fitting hard collars, inadequate communication between clinicians and the neurosurgical team about treatment options, and a lack of risk-benefit consideration for patient decision-making.
Addressed to: Calderdale and Huddersfield NHS Foundation Trust
AI-generated concerns summaryA falls risk assessment was not completed for Mr Price within 24 hours of admission, which meant specific fall risks and mitigation measures were not identified. No subsequent action has been taken by the ward to address these gaps for patients admitted from care homes.
Addressed to: Somerset NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies inconsistent quality and limited detail in patient information provided to radiologists for scan interpretation, including a lack of patient symptoms. This restricted focus may lead to only limited aspects of a scan being interpreted, potentially delaying diagnosis and treatment.
Addressed to: South Tyneside and Sunderland NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that current outcome codes do not indicate when a patient refuses treatment, leading to critical safeguarding information being missed. The use of 'advice given' as an outcome can also create a misleading impression of events.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that an elderly patient's unnecessary hospital admission due to insufficient staffing contributed to a pressure sore, which district nurses did not treat with appropriate frequency. There was also a lack of organisational reflection and preparedness by a district nursing manager for inquest.
Addressed to: Chief Executive Whittington Health NHS Trust Whittington Hospital
AI-generated concerns summaryThe coroner raises concerns that the public, particularly young people, do not fully understand the dangers and health risks of acute and chronic ketamine use, partly due to its classification as a Class B drug.
Addressed to: Secretary of State for Education; Secretary of State for Health And Social Care; Secretary of State for the Home Department
AI-generated concerns summaryThe coroner identified a lack of planning for patient transport, an ineffective investigation into the death of a detained patient, and poor communication between emergency services, which delayed assistance and prolonged distress.
Addressed to: Chief Constable Greater Manchester Police; Chief Executive North West Ambulance Service; Chief Executive Oldham Borough Council; Chief Executive Pennine Care NHS Foundation Trust