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 raises concerns about the lack of specific guidance for sellers, particularly online, regarding purchases of small quantities of a reportable poison often incorrectly presumed for legitimate use rather than potential self-harm.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified inadequate mental health assessments, a failure to elicit critical information from the patient despite her repeated attempts, and poor communication within mental health teams and with her GP. There was also a lack of professional curiosity and detailed record-keeping.
Addressed to: Essex Partnership University NHS Trust
AI-generated concerns summaryThe coroner noted a lack of discussion regarding family involvement in the young adult's mental health care plan and insufficient training for the Residential Adviser in responding to hangings, leading to no attempts to cut her down.
Addressed to: NHS England; NHS Improvement, Patient Safety Team
AI-generated concerns summaryThe coroner noted that resources for safeguarding intoxicated individuals with mental health illnesses may be placing people at risk, as a suicidal person could not be adequately safeguarded until sober enough for a mental health assessment.
Addressed to: Department of Health and Social Care; Hartlepool Council; Integrated Care Board (NHS North East and North Cumbria); Middlesbrough Council; Redcar Council; Stockton Council; Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the lack of a clear care plan and robust risk assessment for Mr. Fraser. Concerns were also raised about the Mental Health and Wellness Team's delayed response to loss of contact, affecting risk review and missing person procedures.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner identified that the "Right Care, Right Person" procedure resulted in police non-attendance despite immediate risk and the need for forced entry. It was also noted that the review process for these decisions could cause critical delays.
Addressed to: Durham Constabulary; Officer of the College of Policing
AI-generated concerns summaryThe coroner identified lengthy A&E waiting times, a lack of timely medical triage, and insufficient clinical information during follow-up calls. Concerns also included failures to promptly share patient results with GPs and ensure direct parental discussion for minors.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe police implemented the RCRP initiative without sufficient consultation with other emergency services, leading to a lack of clear agreement on how to respond to welfare concerns in complex situations. This creates a gap in coordinated emergency service response.
Addressed to: West Yorkshire Police
AI-generated concerns summaryThe coroner identified that observation scores following a fall were not fully recorded in Mr Ineson's care notes, creating a gap in evidence for reviewing the need for escalation to medical services. This inaccurate record-keeping system poses a risk of future deaths.
Addressed to: BARCHESTER HEALTHCARE LIMITED
AI-generated concerns summaryThe coroner noted that initial forensic collision investigation terms of reference omitted instructions to measure the distance between pursuing and subject vehicles. This impacted the inquest by not providing clear objective evidence to the jury.
Addressed to: Independent Office for Police Conduct
AI-generated concerns summaryThe coroner noted a failure by the Metropolitan Police Service to effectively implement, disseminate, and train staff on relevant policies. There was also an inconsistent expectation among police officers regarding the time taken for pursuit authorisation decisions.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted unclear guidance for mental health staff on information sharing and gathering with family members, specifically regarding the distinction and recording of these actions. Additionally, patient information leaflets lacked sufficient detail for patients to understand these processes.
Addressed to: Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner identified that hospital electronic systems could not communicate with out-of-area community nursing services, preventing efficient referrals and leading to delayed patient care after discharge. This created a risk for patients requiring ongoing community support, particularly those treated at regional centres living outside the usual catchment area.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the poor management of MW’s nutritional needs during her hospital admission. This included a failure to heed family concerns, formally monitor dietary intake, or respond to signs of malnutrition, with dietary interventions considered too late.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner identified poor nursing care and treatment that possibly contributed to the death, and which raised a mortality risk for other patients. No evidence was provided that these concerns have since been addressed.
Addressed to: NHS University Hospitals Trust Plymouth
AI-generated concerns summaryThe coroner noted concerns that an investigation into care was not thorough, lacking statements from directly involved doctors and relying on incomplete records. There was also insufficient contextual sharing of investigation findings with staff.
Addressed to: Betsi Cadwaladr University Health Board (BCUHB)
AI-generated concerns summaryThe coroner identified a lack of policy at WMFS for investigating work-related deaths to learn about welfare support, and noted that existing wellbeing policies do not provide sufficient support for senior staff facing stressors or disciplinary investigations.
Addressed to: West Midlands Fire Service
AI-generated concerns summaryThe coroner noted that some GPs do not book follow-up appointments for patients with mental health difficulties, instead requiring patients to book their own. This practice can prevent patients from receiving necessary follow-up care or medication.
Addressed to: Royal College of General Practitioners (RCGP)
AI-generated concerns summaryThe information provided to pregnant patients on induction at 40 weeks does not fully reflect NICE guidance regarding risks of continuing pregnancy. There is also a lack of consistent understanding among midwives about when to escalate concerns for labouring mothers and CTG traces.
Addressed to: Princess Alexandra Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that GP medical history summaries are not always accessible to out-of-hours GP surgeries due to incompatible computer systems, even with patient consent, hindering appropriate medical examinations.
Addressed to: Care Quality Commission; Holderness Health – Hedon Group Practice; NHS England; Royal College of General Practitioners