Browse 6,458 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 summaryNottingham University Hospitals lacked robust systems for promptly identifying and retaining clinical evidence post-incidents, hampering investigations. Additionally, the Integrated Care Board's slow rollout of a penicillin allergy de-labelling pathway risks patients receiving higher-risk alternative antibiotics.
Addressed to: Nottingham and Nottinghamshire Integrated Care Board; Nottingham University Hospitals NHS Trust
AI-generated concerns summaryKent Police lacks a specific policy for risk assessing and safety-netting individuals arrested for online child sexual abuse and exploitation. Additionally, officers receive no mandatory face-to-face refresher training on welfare checks.
Addressed to: Kent Police
AI-generated concerns summaryAmbulance Support Practitioners, who are often first on scene at out-of-hospital cardiac arrests, are trained to use i-gels for airway securement only under paramedic supervision.
Addressed to: North East Ambulance Service
AI-generated concerns summaryThe coroner identified gaps in emergency department staff familiarity with guidelines for follow-up chest x-rays in pneumonia patients and the process for arranging them post-discharge. A system is also lacking for reviewing radiology reports that arrive after patients have been discharged from the ED.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted clinicians did not follow guidance for reviewing antibiotic treatment or ordering microbiology tests when infections persisted. Current systems and electronic records lack proactive mechanisms to drive re-evaluation of ineffective infection treatment.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an increased risk to pedestrians crossing the A620 due to the expanded overflow car park, noting that only 'SLOW' signage was installed, rather than the planned 'PEDESTRIANS IN THE ROAD/CROSSING' signs, which leaves drivers unaware of the risks.
Addressed to: Nottingham County Council
AI-generated concerns summaryThe coroner identified a need for clarity on the ambulance service's policy for declining welfare calls and how this aligns with the police's 'Right Care Right Person' policy, which creates uncertainty about responsibility for welfare checks.
Addressed to: North West Ambulance Service
AI-generated concerns summaryThe coroner identified inadequate analysis by SWAST NHS, noting paramedics did not identify a potential aortic dissection given the patient's history and symptoms, which delayed life-saving surgery. The clinical review also contained an error in recording the patient's aneurysm type.
Addressed to: Association of Ambulance Chief Executives; South Western Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted the patient was denied prescribed hormonal therapy without rationale. Concerns also focused on staff misunderstanding Section 17 leave policies, a deficient electronic recording system, and insufficient scrutiny of repeated unauthorised absences.
Addressed to: Essex Partnership University NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding insufficient trained staff and inappropriate security personnel for enhanced observations. There was also a lack of care plans and risk assessments for ligature risks for a patient with severe self-harm risks in an unsuitable hospital environment.
Addressed to: Mid & South Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified significant inaccuracies and omissions in medical records regarding Abbi's diagnosis, care, and medication regimes. Concerns also included the lack of an individualized care plan and insufficient adjustments for her autism and learning difficulties.
Addressed to: Cygnet Health Care
AI-generated concerns summaryThe coroner raised concerns about a complex patient's management by junior clinicians, an incorrectly reapplied diagnosis, and inadequate adherence to treatment plans including medication and urgent follow-up. Poor record-keeping was also noted.
Addressed to: Essex Partnership University NHS Trust
AI-generated concerns summaryThe NHS 111 script for minor wounds may inappropriately be applied to head injuries, leading to basic first aid advice instead of clinical assessment. Any injury above the neck should follow the head injury pathway to ensure a clinician provides advice.
Addressed to: Yorkshire Ambulance Service NHS Trust 2. NHS PathwaysI am also sending this to the family of Christine Clegg and HC – One The Kind Care Company (Kesteven Grange Care Home Hull).2.CORONERI am Sally Robinson, Assistant Coroner, for the coroner area of East Riding of Yorkshire and City of Kingston Upon Hull.3.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and; NHS Pathways; Yorkshire Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified financial barriers to Ms Heath accessing recommended at-home anticoagulation monitoring, which prevented her from achieving a therapeutic INR. Concerns also included the absence of a funding application, inadequate medical record-keeping, and insufficient specialist review.
Addressed to: Integrated Care Board, Mid and South Essex; Mid and South Essex NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner noted a need for funding to provide appropriately qualified dieticians to meet the nutritional needs of psychiatric inpatients within SPFT and other Trusts lacking such support.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe South London & Maudsley NHS Foundation Trust had inconsistent risk assessments and inadequate systems for managing and monitoring voluntary patient leave, with poor documentation and communication. Separately, the Metropolitan Police Service's rigid policy application resulted in delayed deployment.
Addressed to: College of Policing; Metropolitan Police Service; South London & Maudsley NHS Foundation Trust
AI-generated concerns summaryConflicting information between hospital staff and the Mental Health Liaison Team (MHLT) regarding MHLT's 24/7 service availability and referral procedures meant the patient did not receive a mental health review.
Addressed to: Shrewsbury and Telford Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a lack of a documented system and formal process to manage planned, prolonged absence of care co-ordinators in the Youth team, which creates a risk of insufficient continuity of care for mental health patients.
Addressed to: Norfolk and Suffolk NHS Foundation Trust (NSFT)You are under a duty to respond to this report within 56 days of the date of thisreport, namely by 18th July 2026. I, the coroner, may extend the period if an appropriate application is made.2.CORONERI am Daniel Sharpstone, Assistant Coroner for the Coroner area of Suffolk.3.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and; Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identified increasing pressures on acute mental health bed provision, locally and nationally, leading to reliance on crisis houses which lack the same clinical capacity and are not ligature-safe. Concerns were also raised about long waiting times for psychological assessments.
Addressed to: Secretary of State for Health and Social Care
AI-generated concerns summaryThe coroner identified an under-resourced Safer Custody function, an unrobust telephone line system, and insufficient systems for learning from deaths. Concerns also included the Care and Separation Unit's failure to adhere to policy.
Addressed to: HMP Lowdham Grange; Northamptonshire Healthcare NHS Foundation Trust; Nottingham and the Head of Healthcare