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 Home Treatment Team had an excessive number of patients, which created difficulties in holding effective multi-disciplinary meetings due to the large caseloads.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified deficiencies in police training on positional asphyxia and vehicle design affecting detainee monitoring. Concerns describe insufficient Security Industry Authority oversight, training, and auditing for door supervisors regarding restraint dangers and asphyxia risks.
Addressed to: Home Office; North Wales Constabulary; Security Industry Authority
AI-generated concerns summaryThe coroner noted concerns about reduced driver visibility at a junction due to the proximity of parking, creating a serious risk for road users. The report also questioned the appropriateness of the parking and the designation of 'the ramp' as an adopted highway.
Addressed to: Rochdale Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted that hospital staff were unable to directly refer Mr. Ikken to community psychology services upon his discharge from the hospital.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that the electronic patient record system (RiO) did not summarise significant patient history, making it difficult for assessing nurses to access crucial information in a timely manner.
Addressed to: South West London and St George’s Mental Health Trust
AI-generated concerns summaryVERONICA HAMILTON-DEELEY, LLB.
Addressed to: Brighton and Sussex University Hospitals; National Patient Safety Agency; National Research Ethics Service
AI-generated concerns summaryThe coroner noted the sale of potentially fatal gases by local retailers to the deceased, despite awareness of her substance use. Concerns were raised regarding the lack of specific legislation or regulatory powers for Trading Standards to prevent such sales.
Addressed to: Department for Business Innovation and Skills; Oldham Metropolitan Borough Council; Public Health England; Trading Standards Institute
AI-generated concerns summaryThe coroner noted the increased risk of self-harm for vulnerable young persons with complex needs in Youth Offender Institutions, which staff find difficult to manage effectively. Concerns were also raised about some staff's suitability and understanding of these needs.
Addressed to: HM Youth Offenders Institute Hindley; Ministry of Justice; National Offenders Management Service; Youth Justice Board
AI-generated concerns summaryThe coroner noted that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery due to the risk of uterine rupture and associated obstetrical complications.
Addressed to: Southend University Hospital
AI-generated concerns summaryThe coroner noted delays in revision hip surgery due to unavailable information on the type and specification of the deceased's implants. Concerns were raised regarding the absence of a formal patient document or a hospital system for accessible implant details.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted ineffective communication regarding the length of the second stage of labour to senior staff due to an unmonitored whiteboard system. There was also uncertainty among midwifery and medical staff concerning the updated escalation policy and adherence to its time limits.
Addressed to: University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner noted the perimeter wall's low height (3 feet) and the presence of a crash-protective barrier acting as a step, making it easy for individuals to gain access to the top of the wall, creating a dangerous situation.
Addressed to: Q-Park Limited; Sheffield City Council (Planning); Sheffield County Council
AI-generated concerns summaryThe coroner identified a lack of staff training in managing risks from illicit substance use on wards with dual diagnosis patients. Concerns were also raised about the failure to use incident reporting systems for drug supply/consumption, and the absence of a clear policy between the Mental Health Trust and Police …
Addressed to: Secretary of State for Health
AI-generated concerns summaryThe coroner identified a lack of regular consultant physician input for inpatients with physical health problems in psychiatric settings, which led to delays in obtaining specialist medical opinions for conditions such as hyponatraemia.
Addressed to: South London and Maudsley NHS Trust
AI-generated concerns summaryA message from Ms Turner's solicitor about her mental health concerns was left for her CPN but remained unread until the next day, indicating a delay in processing important patient information.
Addressed to: North Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding delays in private sector investigations requiring NHS transfer, inconsistencies in advice for young athletes with syncope, and the lack of a consistent national approach to managing such cases.
Addressed to: BMI Hospital Thornbury; Department of Health and Social Care; NHS England; Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryPPO and Clinical Review reports were not shared with the healthcare provider at HMP Liverpool, potentially reducing the optimal effect of recommendations.
Addressed to: Prison and Probation Ombudsman
AI-generated concerns summaryA junior doctor did not recognise a sub-therapeutic sodium valproate level due to an unclear reference range, which delayed the recognition that the patient was not taking their anti-epilepsy medication.
Addressed to: University College London Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a lack of professionalism and leadership in the custody suite, where inappropriate behaviour and banter were common. There was insufficient evidence of guidance or training for staff on acceptable conduct, indicating a need for cultural change within custody suites.
Addressed to: West Midlands Police
AI-generated concerns summaryThe coroner noted concerns regarding GP practices closing for staff training without a doctor available for emergencies during normal hours, and the impact of a significant delay in assessing an obviously unwell patient leading to delayed hospital referral.
Addressed to: Fountain Medical Centre; Leeds West Clinical Commissioning Group