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 effectiveness of the ACCT process at HMP Styal, noting that mental health input is often minimal and not therapeutic. The prison's environment and processes are not adequately addressing the high and complex mental health needs of the women detained there, particularly those awaiting transfer …
Addressed to: HMP Styal; HMPPS; Prisons, Probation and Reducing Reoffending; Ministry of Justice
AI-generated concerns summaryThe coroner raises concerns that barriers at [REDACTED] remain surmountable, allowing individuals to fall, despite two previous similar deaths. Insufficient operational security and a lack of CCTV monitoring contribute to the ongoing risk.
Addressed to: [REDACTED], and
AI-generated concerns summaryConcerns included inadequate recording of vital observations and staff training at the hospital, alongside long patient waiting lists resulting from staffing shortages and rejected funding requests from NHS England.
Addressed to: Department of Health and Social Care; NHS England; Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that kerbing at the end of a residential cul-de-sac was below standard height and lacked devices to prevent vehicles from entering the adjacent canal, a hazard that had occurred twice in five years.
Addressed to: West Sussex County Council
AI-generated concerns summaryThe coroner noted insufficient review and oversight of long-term opiate prescriptions for patients within the practice. There was also a significant delay between identifying a patient on such a prescription and the next planned action.
Addressed to: Flixton Road Medical Centre; Greater Manchester Integrated Care Board
AI-generated concerns summaryReferral documents completed by medical practitioners at the practice only generate an alert to colleagues if manually selected, rather than automatically upon completion of the document.
Addressed to: Townhead Surgery
AI-generated concerns summaryThe coroner noted the absence of systems for prioritising urgent surgical patients and for monitoring their clinical parameters while awaiting transfer from Bassetlaw's ED to DRI.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of physical barriers on a grass verge separating two 70MPH roads, allowing vehicles losing control to cross into parallel lanes and risking high-speed collisions.
Addressed to: Kent Police; National Highways; The Chief Coroner
AI-generated concerns summaryThe coroner noted that a specific obstetric manoeuvre, the 'shoulder shrug', used during delivery is not included in current NICE guidelines and suggested it be considered for future updates.
Addressed to: Royal College Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted a risk of future deaths on the A4059 due to reduced visibility from road bends, speed, and vehicles turning right across the carriageway from a parking bay, even with impending speed limit changes.
Addressed to: Rhondda Cynon Taf County Borough Council; Welsh Government
AI-generated concerns summaryAdult Social Care failed to process safeguarding and carer's assessment referrals, and a priority referral was inappropriately downgraded without adequate review. The coroner raises concerns about the lack of robust oversight to identify suboptimal managerial decision-making within the service.
Addressed to: Essex County Council
AI-generated concerns summaryThe coroner noted a lack of codified risk and safety planning for families of psychiatric patients on leave, and unfettered in-patient Wi-Fi access to self-harm websites. There was also concern about insufficient menopausal care within the NHS.
Addressed to: National Institute for Health and Care Excellence; NHS England; Royal College of General Practitioners; Royal College of Obstetricians and Gynaecologists; Somerset Foundation Trust
AI-generated concerns summaryThe coroner identifies a lack of a clear system to establish responsibility for the management and safety of accessible shipwrecks, meaning safety concerns cannot be raised and the wreckage lacks sufficient warnings.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner raised concerns about unregulated online pharmacies selling prescription-only medicines and controlled drugs, which are easily found and appear legitimate. These sites lack verification of patient medical history, dosage guidance, and safeguards, potentially exposing vulnerable individuals and minors to unsafe medications.
Addressed to: Department for Digital, Culture, Media and Sport; Department of Health and Social Care
AI-generated concerns summaryThe coroner identifies an over-reliance on self-reporting and a lack of continuous objective visual checks in the UK's driver licensing system. This allows drivers with impaired vision, especially those over 70, to remain licensed without effective oversight or sanctions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified significant underreporting of dementia among drivers to the DVLA, noting that the current self-reporting system is unsafe because dementia impacts self-awareness. This allows drivers with cognitive impairments to remain licensed, posing a risk.
Addressed to: Department for Transport
AI-generated concerns summaryLondon Underground's corporate thinking does not sufficiently prioritise the risk of intoxication to individual passengers, despite knowing that some will be intoxicated. Learning from a previous investigation appeared aspirational without a concrete plan.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner noted a lack of guidance for surgeons to consider CT scans for patients after major abdominal surgery when C-reactive protein (CRP) levels are high and not decreasing. This can lead to objective blood test results not being adequately factored into discharge decisions.
Addressed to: Association of Coloproctology of Great Britain; Department of Health and Social Care; Royal College of Surgeons
AI-generated concerns summaryThe coroner noted deficiencies in Royal Berkshire Hospital's death investigation process, including delayed morbidity meetings, poor structured judgement reviews, and unreliable record systems. Concerns were also raised about the trust's management of a specific surgeon.
Addressed to: Royal Berkshire NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies an absence of a set national procedure for UK hospitals accepting international patients, leading to inconsistent transfer processes and a risk of patients arriving in a worse condition. Gaps exist in systems to ensure safe reception and treatment with accurate medical information.
Addressed to: Department of Health and Social Care; Foreign, Commonwealth and Development Office; Home Office; NHS England