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 noted flaws in Mills Family Ltd's investigation into a patient's fracture, including a lack of detailed guidance and training for managers on conducting investigations. There was also a delay in the London Borough of Bromley's request for a provider-led report.
Addressed to: London Borough of Bromley; Mills Family Ltd
AI-generated concerns summaryThe coroner identified significant and persistent waiting list backlogs for gynaecology referrals, which risks patients deteriorating and losing treatment options. There is no system to monitor the progress of patients on these waiting lists, potentially leaving them waiting excessively without review.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe discharge passport contained inaccuracies regarding patient vulnerabilities and equipment, which were not identified during screening. This led to a missed welfare check, delayed social worker visits, and an incorrect District Nursing referral that delayed assessment.
Addressed to: Lewisham and Greenwich NHS Trust; London Borough of Lambeth; London Borough of Lewisham
AI-generated concerns summaryThe coroner raised concerns that patients with "cliff-edge conditions" who are medication-dependent are not adequately identified within the health system. This leads to insufficient patient awareness of risks, lack of urgent support, and inadequate safety-netting advice in the event of a sudden crisis.
Addressed to: NHS England
AI-generated concerns summaryThe report highlights the absence of a policy for welfare checks when First Night Interviews cannot occur, and inadequate communication regarding changes to a prisoner's cell-sharing risk status. Probation input was also missing from the Open Conditions Suitability Assessment.
Addressed to: HM Inspectorate of Prisons; Ministry of Justice
AI-generated concerns summaryThe coroner identified late engagement by the Community Offender Manager and insufficient planning for the prisoner's accommodation upon release. Concerns include a failure to inform local authorities about impending homelessness and a lack of support for the prisoner to understand his release conditions.
Addressed to: HMPPS; HMP Wymott
AI-generated concerns summaryConcerns were raised about delays in responding to a student welfare check, including the time taken to physically attend the room and staff closing the door after initial observations instead of immediately escalating to emergency services.
Addressed to: Unite Group plc
AI-generated concerns summaryThe coroner noted insufficient awareness among care homes regarding the availability of anti-choking devices, particularly in settings with high-risk residents. It was suggested that wider knowledge and provision of these devices could help reduce choking deaths.
Addressed to: Birmingham and Solihull Integrated Care Board; Health and Safety Executive
AI-generated concerns summaryFluid balances were not effectively monitored, leading to clinicians making decisions without important information and hindering internal hospital reviews from learning correct lessons.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a risk of future deaths on a section of the A48 that has seen multiple fatal and serious collisions, particularly for cyclists. This is due to varied road design, inconsistent speed limits, and a lack of active travel routes or cyclist safety modifications.
Addressed to: Bridgend County Borough Council; Welsh Government
AI-generated concerns summaryThe coroner identified inadequate pain assessment for non-verbal patients and insufficient basic chest examinations for learning disabled adults at risk of pneumonia in the emergency department, alongside inadequate escalation of high NEWS2 scores.
Addressed to: Care Quality Commission; Hull University Teaching Hospitals NHS Trust; NHS England
AI-generated concerns summaryA paramedic was unaware that stroke symptoms can stop temporarily, conflicting with evidence about training. The treating chiropractor also did not request recent medical records before assessment, and the British Chiropractic Association consent form does not prompt this.
Addressed to: General Chiropractic Council; North East Ambulance Service
AI-generated concerns summaryThe report highlights the cardinal principle that a doctor should not treat a close relative. No suspicious conduct was suggested in the matter.
Addressed to: General Medical Council
AI-generated concerns summaryThe coroner identified gaps in policies and staff training for barricading incidents and agency staff CPR competency. Concerns included environmental risks from mobile furniture and ligature points, and insufficient information sharing between probation services and prisons.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner noted potential issues with surgical jigs becoming deformed from repeated use and the absence of quality control or auditing for their integrity before surgery. A specific jig relevant to the case was lost, preventing its analysis.
Addressed to: Stryker (UK) Ltd; British Orthopaedic Association
AI-generated concerns summaryThe coroner noted that the housing situation, including eviction, homelessness, and separation from family due to a shortage of public housing, significantly impacted Paul Williams' mental health. The delay in securing suitable accommodation contributed to his deteriorating condition.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryCheshire Police had unclear processes for managing reports, with no mechanism to confirm that actions were being taken following observation requests. There was also confusion within the control room about adding vehicles to ANPR, and identified training was delayed.
Addressed to: Cheshire Constabulary
AI-generated concerns summaryInformation on suicide prevention services is not effectively provided to young people, and existing contact numbers are often unanswered or inaccessible to those with disabilities. There are also concerns about potential reductions in mental health services due to funding.
Addressed to: Sussex Partnership Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about incomplete nursing documentation regarding anticoagulation medication and compression stockings post-surgery. This included a lack of reporting such omissions, suggesting insufficient awareness among nurses of their professional duty to complete and report documentation.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner raises concerns that frequent care in corridors and non-clinical spaces at Princess of Wales Hospital impedes clinical assessment, hinders recognition of patient deterioration, and reduces emergency department capacity. This issue is exacerbated by significant delays in discharging medically fit patients due to non-medical reasons.
Addressed to: Cwm Taf Morgannwg University Health Board