Browse 6,493 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 summaryThe coroner identifies delays in the decision-making and funding processes for long-term therapeutic placements, noting concerns that such delays could negatively impact an individual's mental health and contribute to self-harm or death.
Addressed to: Haringey Council
AI-generated concerns summaryThe coroner identified concerns regarding the ease with which vulnerable individuals can purchase prescription-only drugs online without medical supervision, posing a risk to their health.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryCommunication issues meant post-discharge patient contacts indicating worsening symptoms were not reported to the inpatient Consultant for timely self-harm risk assessment. There were also deficiencies in systems for quickly locating patients identified as having an immediate risk of self-harm.
Addressed to: Black Country NHS Partnership Trust
AI-generated concerns summaryThe EMIS computer system for GPs only flags patients for review if they are on current regular prescriptions, meaning those with chronic diseases who have stopped treatment are not identified for necessary monitoring. This poses a risk of preventable deaths for patients with conditions like asthma and epilepsy.
Addressed to: Department of Health and Social Care; EMIS Health; Iveagh Surgery
AI-generated concerns summaryThe coroner noted insufficient staff vigilance regarding inmate social gatherings and a lack of training for staff in breathalyser use and emergency codes. Concerns were also raised about unrecorded inmate behaviour in observation books and delays in summoning paramedic assistance.
Addressed to: Solicitors; Leeds Community Healthcare NHS Trust; Solicitors; National Offender Management Service
AI-generated concerns summaryThe care home manager did not provide the falls risk assessment at the inquest. The coroner also noted that a carer was unfamiliar with a resident's high falls assessment and care plan, which the manager acknowledged was their responsibility to ensure staff knew.
Addressed to: Hawthorn Green Care Home; Sanctuary Care Limited
AI-generated concerns summaryConcerns included the danger of tramlines for cyclists, a confusing bicycle lane design at a junction that may lead to unsafe crossings or interactions with pedestrians, and unclear signage implying tram routes are cycle routes.
Addressed to: London Borough of Croydon
AI-generated concerns summaryThe coroner notes that e-cigarettes powered by lithium-ion batteries are at risk of explosion if charged with an incorrect current from a compatible micro USB charger.
Addressed to: Department for Business, Innovation and Skills
AI-generated concerns summaryThe coroner identified a lack of communication between prison units regarding a prisoner's transfer plan and risk assessment. Documentation for detention contained errors due to copying, and senior managers were unaware of rules for transferring ACCT prisoners to segregation.
Addressed to: HMP Long Larkin
AI-generated concerns summaryPolice response timeliness, call grading protocol adherence, and inter-agency communication gaps were identified. Additionally, a psychiatric practice's limited correspondence with GPs affected continuity of care.
Addressed to: Greater Manchester Police; Green Surgery; MEDACS Healthcare
AI-generated concerns summaryDelays occur in patients receiving additional investigations because radiologists recommend tests that GPs must request, even when GPs cannot directly instigate them. This process, influenced by commissioning arrangements, could increase the risk of future deaths.
Addressed to: Barts Health NHS Trust; NHS Tower Hamlets Clinical Commissioning Group; NHS England; Tredegar Practice
AI-generated concerns summaryA patient's prescribed medication was not delivered due to an unconnected syringe driver on a surgical ward, and the device was then not transferred with him to hospice, interrupting his essential pain relief.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of out-of-hours cardiology consultant cover, echocardiogram facilities, and qualified staff for pacing wire procedures at Tameside Hospital. Further concerns included patient capacity and consent issues, critical drug shortages, and communication failures.
Addressed to: Department of Health and Social Care; Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the premature and incorrect classification of the offence, misleading entries in the police recording system, and sub-optimal supervision of the investigation. Gaps were also identified in police standard operating procedures for non-adult domestic violence cases and the use of interpreting services.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted that the decision to treat Mr. Vickery at a clinic instead of his home disregarded his GP's request. Southern Health's Integrated Community Services should formally consult with GPs regarding treatment location decisions.
Addressed to: Southern Health NHS Trust
AI-generated concerns summaryA prison officer did not check Mr Oliver's well-being during cell unlocking, a recurring issue at the prison. The coroner also identified no requirement for officers to record compliance with new procedures for obtaining a response from prisoners.
Addressed to: HMP Northumberland
AI-generated concerns summaryThe building design lacks an entrance lobby to arrest falls, increasing the risk of serious injury from impact with the external door. The communal stairs are also made of smooth concrete without a non-slip surface.
Addressed to: Home Group
AI-generated concerns summaryThe coroner identified a lack of routinely available master keys at the guard room for buildings at Perham Down Barracks and other sites, which could hinder emergency access.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted issues with the location, current state, and overall effectiveness of road signage in a particular area. Concerns were also raised regarding delays in implementing recommendations from a road safety assessment report, pending a coroner's PFD report.
Addressed to: Wiltshire Council
AI-generated concerns summaryThe coroner identified that old glass in properties often does not meet current safety regulations, and landlords have no legal requirement to specifically check its safety. This means replacement typically occurs only during refurbishment or after breakage, which resulted in a death.
Addressed to: Department for Communities and Local Government