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 summaryThe coroner identified an absence of prescribed timeframes in policies for substance misuse intervention and support for prisoners, which poses a risk of delayed assistance.
Addressed to: Cwn Taf Morgannwg University Health Board; G4S
AI-generated concerns summaryConcerns included a failure to prioritise a seriously ill patient and adequately recognise critical diagnoses (APS, AD) from medical alerts or records. This led to insufficient specialist liaison and delays in fluid administration and hypoglycemia treatment.
Addressed to: York & Scarborough NHS Trust
AI-generated concerns summaryThe coroner raises concerns about the current algorithm for assessing ill newborns/infants, noting its inadequacies in identifying respiratory problems and that reliance on it can delay early clinical assessment.
Addressed to: NHS England; South Central Ambulance Service
AI-generated concerns summaryThe coroner noted that cell bedding material allowed a ligature to be made, and identified inconsistent officer training and understanding regarding ACCT procedures, first aid, basic life support, and the Mental Capacity Act.
Addressed to: His Majesty’s Prison and Probation Service
AI-generated concerns summaryThe coroner identified concerns regarding the speech and language therapy assessment process and insufficient training for care home staff in basic life support, nutritional risk assessment, and specific dietary requirements.
Addressed to: Hillcare Group; Northumbria Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient dialogue between leaders to learn from a severe incident and prevent reoccurrence, along with inconsistent responses regarding major medical emergencies in prison. Concerns were also raised about continued confusion over which public body has primacy during acute medical emergencies in a custodial setting.
Addressed to: HMP Elmley; Oxleas NHS Foundation Trust; South East Coast Ambulance Service
AI-generated concerns summaryThe coroner noted confused communication and an absence of a clear command structure among prison staff, healthcare professionals, and paramedics during a medical emergency. There remained a lack of clarity on roles and responsibilities, and how such situations would be managed in the future.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns about the lack of an obvious external warning label on a flue-less LPG cabinet heater, meaning users might not be aware of the minimum safe room dimensions to prevent carbon monoxide build-up, particularly in rented properties.
Addressed to: Office for Product Safety and Standards
AI-generated concerns summaryMany platform lifts in care settings and other premises lack hold-to-run controls, despite these being retrofittable at low cost. There is limited awareness of both the risks posed by this absence and the feasibility of fitting such devices.
Addressed to: Department of Health and Social Care; HSE; Lift and Escalator Industry Association
AI-generated concerns summaryThe coroner noted that the lack of evening and weekend physiotherapy services in the hospital caused discharge delays, exposing patients who were medically fit but awaiting assessment to unnecessary risks in an acute hospital environment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted delays in the diagnostic, staging, and treatment phases for suspected cancer, particularly regarding the time taken to complete staging scans. These ongoing delays are affecting survivability rates and prognoses.
Addressed to: ABMU HEALTH BOARD
AI-generated concerns summaryThe coroner identified a lack of joint agency policy and cross-sector working on Acute Behavioural Disorder/Disturbance among front-line services. There was also an absence of a consistently agreed joint policy between EMAS and the police concerning s.136 Mental Health Act 1983 detentions.
Addressed to: College of Policing; Custodial Services; Department of Health and Social Care; East Midlands Ambulance Service; Faculty of Forensic & Legal Medicine of the Royal College of Physicians; Nottingham and Nottinghamshire Police; Nottinghamshire Healthcare NHS Foundation Trust; Royal College of Emergency Medicine; The Judicial and Coronial System
AI-generated concerns summaryThe coroner noted concerns regarding the sufficiency of staff to ensure resident safety, particularly when staff members are engaged in activities that may divert their attention from residents.
Addressed to: Ashton Lodge Care Home
AI-generated concerns summaryThe coroner noted concerns regarding the excessively long waiting lists for first appointments at Gender Dysphoria clinics.
Addressed to: Department of Health and Social Care; Tavistock and Portman NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the ability to locate trespassers on railway lines at night is made difficult by the absence of suitable lights on the track or train, which hindered visibility of Mr English.
Addressed to: Department of Transport; Rail Safety Board; Transport for London
AI-generated concerns summaryThe coroner noted a failure to escalate abnormal patient observations and a lack of structured risk assessment for pulmonary embolism. Concerns were raised about unclear use of clinical decision tools and the absence of a specific protocol for recognising and escalating life-threatening conditions in the walk-in centre.
Addressed to: Milton Keynes Urgent Care Service
AI-generated concerns summaryNewly recruited prison officers had an incomplete understanding of the ACCT process and observation requirements, specifically regarding unpredictable timing and staggering observations, following their training.
Addressed to: His Majesty’s Prison and Probation Service
AI-generated concerns summaryThe coroner noted current surveillance programs for respirable crystalline silica (RCS) exposure are insufficient due to rapid disease onset. Many companies working with artificial stone products lack safe working conditions, adequate dust suppression, PPE, and ventilation.
Addressed to: Department of Health & Social Care; Department of Housing, Community and Local Government; HSE
AI-generated concerns summaryThe coroner noted a lack of national and local policy regarding illicitly brewed alcohol (hooch) in prisons. Concerns were also raised about insufficient governance for medication held in possession by prisoners, which could be accessed by others.
Addressed to: Department of Health and Social Care; HMP Guys Marsh; HMPPS; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner highlighted a lack of training for agency staff in compiling risk assessments and insufficient communication with patients' families and friends to gather vital information about their mental health.
Addressed to: Department of Health and Social Care; Hampshire and Isle of Wight Healthcare Foundation NHS Trust