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 a lack of central monitoring for poisoning incidents involving certain substances, which are increasingly used for self-harm. There are no restrictions on importing these substances, and no government department appears to be actively considering regulating their access, purity, or quantities sold to mitigate risks.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe NHS Pathways system for overdose calls does not adequately differentiate between types or severity of ingestion, which impacts response urgency. Additionally, ambulances lack a specific antidote, Methylene Blue, delaying crucial treatment often beyond the point of effectiveness.
Addressed to: NHS England & NHS Improvement; South East Coast Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies an under-appreciation of the risks posed by elevated levels of Propranolol, a drug widely prescribed to young people for anxiety. This issue was still apparent in evidence presented at a recent inquest.
Addressed to: National Institute of Health and Care Excellence
AI-generated concerns summaryThe coroner identified that Royal College of Pathologists' guidelines for urgent liver function test reporting lack pregnancy-specific thresholds, which delayed the communication of critical results for a potentially fatal condition, leading to a delayed diagnosis.
Addressed to: Royal College of Obstetricians and Gynaecologists; Royal College of Pathologists; South West Regional Midwife; University Hospitals Bristol and Weston NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies gaps in guidance for non-specialist staff on contacting, sharing information with, and transferring kidney transplant patients to specialist renal hospitals. This includes inconsistent understanding of transfer responsibility and a lack of clear protocols for effective inter-hospital coordination.
Addressed to: British Transplant Society; George Eliot Hospital NHS Trust; NHS England; Renal Association; UK Kidney Association
AI-generated concerns summaryThe coroner raises concerns about a lack of specialist rehabilitation accommodation for women at high risk of self-harm, leaving a gap in effective rehabilitative provision. There is also a need for improved training for probation officers on understanding available accommodation options.
Addressed to: HMPPS; Probation Service; Steps2Recovery
AI-generated concerns summaryThe coroner identified concerns about long ambulance response times for falls, which can lead to increased risks of pneumonia and pressure damage. Additionally, there is no local out-of-hours service to assist patients off the floor.
Addressed to: NHS Derby & Derbyshire Integrated Care Board
AI-generated concerns summaryThe coroner noted insufficient communication and lack of a clear policy for informing community support teams about accommodation move processes for service users, particularly those with Emotionally Unstable Personality Disorder. Additionally, no internal review was conducted by the council.
Addressed to: Leicestershire County Council
AI-generated concerns summaryThe coroner noted a lack of capacity assessment when the deceased left the hospital before clinical assessment, especially given a suspected head injury. There was also no consideration of undertaking investigations during waiting times.
Addressed to: NHS ENGLAND; SALFORD ROYAL HOSPITAL FOUNDATION TRUST
AI-generated concerns summaryThe coroner noted insufficient monitoring of sevoflurane bottles at Cannock Chase Hospital, allowing one to be removed undetected. The trust could not confirm the origin of a bottle found at the deceased’s home.
Addressed to: Cannock Chase Hospital; NHS England
AI-generated concerns summaryThe coroner raised concerns that medical staff did not consider appendicitis, including retrocaecal presentations, as a diagnosis. This was compounded by insufficient availability and use of ultrasound scanning, and a need for improved doctor training in diagnosing the condition.
Addressed to: Royal College of General Practitioners; Royal College of Paediatricians and Child Health; Royal College of Radiologists; Royal College of Surgeons
AI-generated concerns summaryThe coroner noted residents climb onto balconies to clear blocked drainpipes, posing a fall risk, and that a lack of remedial work means this unsafe practice is likely to continue.
Addressed to: London Borough of Hackney
AI-generated concerns summaryThe coroner noted insufficient training for clinicians on the Dual Diagnosis pathway and how to access it. There was also a lack of a robust system for the Front Door Team to efficiently manage its caseload and follow up on referrals, contributing to a missed multi-disciplinary team meeting.
Addressed to: Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the Highway Code is silent on aquaplaning and highlighted the need for greater public awareness, including reducing speed in surface water and basic braking/steering knowledge.
Addressed to: Department for Transport; Driver Vehicle Standards Agency; Royal Society for the Prevention of Accidents
AI-generated concerns summaryConcerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid training on recognising unconsciousness was not prison-specific and new induction instructions had not yet been implemented.
Addressed to: HMPPS; HMP Wandsworth
AI-generated concerns summaryThe first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.
Addressed to: HMPPS; HMP Wandsworth
AI-generated concerns summaryThe coroner noted a chronic national shortage of mental health beds, which meant a patient was discharged from a medical ward without a mental health bed available, leading to inadequate accommodation arrangements.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted that improvements in prison healthcare, particularly regarding identifying and managing acute sickle cell crisis, may not have been nationally replicated or shared across prisons.
Addressed to: Ministry of Justice; NHS England
AI-generated concerns summaryThe coroner notes that national ambulance response time targets for Category 3 calls are not met. Concerns are also raised regarding misleading wording in NHS Pathways call handler scripts, and the cancellation of responses without discussion with the caller.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a lack of suitable accommodation for prisoners released from custody, including Approved Premises and local authority housing, which can lead to homelessness or unsuitable placements and increased difficulties in supervision.
Addressed to: Ministry of Housing, Communities, and Local Government; Ministry of Justice