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 summaryThe coroner identified concerns about residents with reduced mobility and cognitive impairment being left unsupervised in the care home's lounge area, which poses a risk of future falls.
Addressed to: Peterlee Care Home
AI-generated concerns summaryThe coroner identified gaps in clinician understanding of clot risk in Haemoglobin Rainier disease, alongside a failure in the trust's internal investigation to identify a critical missed referral that impacted the patient's care.
Addressed to: East Cheshire NHS Trust
AI-generated concerns summaryThe coroner noted inconsistent medical advice regarding smoking reduction due to a lack of guidance. There is also no standardized practice for practitioners to record discussions about medication side effects, making it unclear if questions were asked.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted the unacceptable use of two different triage systems simultaneously in the Emergency Department, with insufficient resources for the universal adoption of the validated Manchester system.
Addressed to: Chief Executive HUTH2.CORONERI am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire.3.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and; Chief Executive HUTH
AI-generated concerns summaryConflicting clinical views exist on the necessity and timing of echocardiograms for vulnerable patients before surgery, with unclear clinician responsibility for expediting scans. Structured Mortality Reviews also lack relevant subject expertise, potentially affecting future learning.
Addressed to: Oxford University Hospitals NHS Foundation Trust
AI-generated concerns summaryA clinical support worker recorded inaccurate patient observation times, leading to an incorrect medical record and misleading the court. This raises concerns about the reliability of patient records and the integrity of evidence provided.
Addressed to: North London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified mental health risk assessments were incomplete due to over-reliance on self-reported information and insufficient proactive investigation of available background details. This was linked to a culture where assessors expected referrers to provide all relevant information.
Addressed to: Hywel Dda University Health Board
AI-generated concerns summaryThe coroner noted lengthy delays in securing funding and suitable specialist placements for patients with severe dementia. These patients remain in acute hospital wards where they may not be adequately supervised, posing a risk of future deaths.
Addressed to: Birmingham and Solihull Integrated Care Board; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified poor communication and engagement between agencies involved with Ollie, specifically noting a lack of record-keeping for discussions and that Ollie's pronoun preference was not acted upon.
Addressed to: Barnsley Community Academy; Barnsley Metropolitan Borough Council; South West Yorkshire Partnership NHS Trust
AI-generated concerns summaryRisk assessments for impulsive ingestion may lack proactive scope in identifying potential hazards. The coroner also noted insufficient liaison between mental health and acute services during patient transfers, and a lack of routine auditing for expected communication processes.
Addressed to: Coventry and Warwickshire Partnership NHS Trust; University Hospitals Coventry and Warwickshire NHS Trust
AI-generated concerns summaryCrucial information about Caroline's deteriorating mental health was not shared with the appropriate Assertive Outreach Mental Health Team, leading to missed opportunities for intervention. The report also identified a lack of direct referral pathways between Adult Social Care and this mental health team.
Addressed to: Oxfordshire County Council
AI-generated concerns summaryMedical professionals did not advise a patient with cough syncope to stop driving and notify the DVLA, raising concerns that other patients might not receive similar critical guidance.
Addressed to: Middleton Lodge Practice; Nottingham University Hospitals NHS Trust; Sherwood Forest Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the ongoing use of corridors for patient care in the Emergency Department of the Royal Sussex County Hospital when it reaches capacity. This practice persists despite previous Prevention of Future Deaths reports and actions by the NHS Trust to improve patient flow.
Addressed to: Department of Health and Social Care; NHS England & NHS Improvement; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that wheelchair access doors on coaches may be opened from the exterior due to design and operation, and that current risk mitigation relying on passenger warnings may be ineffective. Coach operators also lack the ability to mitigate design-related risks, which rests with the DVSA.
Addressed to: Driver and Vehicle Standards Agency
AI-generated concerns summaryThe coroner noted a lack of clear guidance and protocol for timely referrals from the local hospital to the tertiary centre regarding Hepato-Pancreato-Biliary matters, which resulted in a delay in seeking specialist advice.
Addressed to: Cabinet Secretary for Health and Social Care in Wales, Welsh Government; Cardiff and Vale University Health Board; Cwm Taf Morganwg University Health Board
AI-generated concerns summaryThe Ministry of Defence (MOD) has been aware of a possible link between exposure to nitrobenzene and other explosives and bladder cancer, yet active and past employees exposed to these substances have not been warned to get tested.
Addressed to: Secretary of State for Defence
AI-generated concerns summaryThe coroner identified gaps in risk management, specifically the absence of a relapse prevention plan, a family safety plan, and insufficient engagement with police and safeguarding teams despite a history of identified risks including domestic abuse and threats.
Addressed to: East London Foundation NHS Trust
AI-generated concerns summaryThe coroner noted a lack of national guidance on monitoring and prescribing for hepatitis B reactivation prevention. Concerns were also raised about insufficient specialised commissioning to maintain patient engagement with hepatitis B services after opt-out screening.
Addressed to: British Association for the study of the Liver; UK Health Security Agency
AI-generated concerns summaryThe coroner noted that a British Transport Police dispatcher erroneously moved a priority log from the dispatch queue, delaying response. This occurred despite a policy requiring supervisory oversight for such calls and a lack of computer checks to prevent the error.
Addressed to: British Transport Police
AI-generated concerns summaryThe report identifies that a Clare's Law application was not progressed due to an officer's misunderstanding, preventing multi-agency safety planning. It also notes a lack of clarity in DVDS guidance on when applications must proceed to decision-making.
Addressed to: Bedfordshire Police; Home Office