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 insufficient escalation of National Early Warning Scores (NEWS2), staff preoccupation with personal mobile phones during one-to-one observations, and inaccuracies in patient observation record-keeping.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of Metropolitan Police Service (MPS) guidance for frontline officers regarding their powers under Section 136 of the Mental Health Act, particularly concerning individuals likely to be missing but not yet formally reported.
Addressed to: Metropolitan Police; Prime Life Limited
AI-generated concerns summaryThe coroner raised concerns that current guidance for dental patients taking Clopidogrel does not require pre-procedure checks for clotting function, potentially leading to excessive bleeding after dental procedures.
Addressed to: Scottish Dental Clinical Effectiveness Programme
AI-generated concerns summaryThe coroner noted limited visibility at the junction and that the junction is subject to the National Speed Limit.
Addressed to: Herefordshire Council
AI-generated concerns summaryLack of contemporary medical notes, infrequent clinical observations, and a procedure performed without informed consent on an unconscious patient. The report also notes delays in incident reporting and coroner notification, which impacted the investigation.
Addressed to: Barking, Havering and Redbridge NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the prison's risk assessments and an inexperienced officer setting ACCT observation levels without required supervisory consultation after significant risk incidents. Additionally, the Head of Operations provided incorrect evidence regarding policy and cell bell cover.
Addressed to: HMP Ranby
AI-generated concerns summaryThe coroner raised concerns about out-of-date mobility care plans, a lack of falls minimisation plans, and significant delays in call bell response times at the care home. The report also identified limited provision of emergency alert devices and insufficient corporate oversight.
Addressed to: Avery Healthcare Group
AI-generated concerns summaryInadequate nursing record-keeping failed to document patient fluctuations or confirm condition review prior to discharge. Additionally, deterioration was not escalated to a doctor, and the patient was discharged home in poor physical condition, causing family distress.
Addressed to: Stepping Hill Hospital
AI-generated concerns summaryThe coroner raised concerns about the national guidance for skin cleaning prior to injections, which suggests cleaning is not necessary if skin is clean. The report noted this advice, based on dated evidence, contrasts with the bacterial reduction achieved by alcohol wipes.
Addressed to: Department of Health and Social Care; NHS England; UK Health Security Agency
AI-generated concerns summaryThe coroner noted concerns regarding the significant delay in concluding Mr Stubbs' internal disciplinary process and the length of his suspension, stating that the legitimate expectation for such matters to be dealt with expeditiously was not met.
Addressed to: Independent Office for Police Conduct; West Yorkshire Police
AI-generated concerns summaryThe ambulance service's triage system prioritised mental illness over substance ingestion for a patient with both, leading to a lower category response. This system logic prevents a higher priority being assigned when both conditions are present.
Addressed to: Association Of Ambulance Chief Executives; National Ambulance Service Medical Directors; NHS England
AI-generated concerns summaryConcerns were raised that many clinicians are unaware they can challenge 999 call categorisation by NWAS and seek a clinical review, which could impact ambulance dispatch for critical patients.
Addressed to: Merseycare NHS Trust; NHS England; North West Ambulance Service NWAS
AI-generated concerns summaryThe coroner identified a widespread shortage of appropriate placements for individuals with complex mental health needs, leading to a decline in mental health when community placement broke down. There was no suitable facility for detention under the Mental Health Act.
Addressed to: Cambridgeshire and Peterborough Integrated Care Board; Department of Health and Social Care; NHS England
AI-generated concerns summaryWest Midlands Ambulance Service did not meet the target response time for a Category 2 call, with paramedics arriving over two hours late. This was due to the service operating at its highest surge level, experiencing numerous outstanding incidents and significant ambulance delays at hospitals.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe electronic custody record contained inadequate detail regarding a detained person's mental health concerns, including the risk of ending his own life and history of suicidal ideation. There was also insufficient analysis of these concerns and reasoning for the Criminal Justice Liaison and Diversion Service assessment conclusion within the record.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; Northumbria Police
AI-generated concerns summaryThe coroner identified a lack of enhanced nursing observations for a patient who fell, and insufficient information on efforts to implement them. Concerns were also raised about the quality of the Trust's post-death investigations, which did not address this key issue.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe mortality review was completed incorrectly, containing contradictory terms about whether the death was avoidable, which raises concerns about the accuracy of these reviews and inadequate learning from cases.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the significant delay in ambulance response, which extended beyond the expected survivability of the injury for an Amber 1 call. This delay was due to ambulances waiting at emergency departments to offload patients, making them unavailable to respond to new calls.
Addressed to: SWANSEA BAY UNIVERSITY HEALTH BOARD; WELSH AMBULANCE SERVICE NHS TRUST; WELSH ASSEMBLY GOVERNMENT
AI-generated concerns summaryThe coroner identified a potential risk if current NICE guidelines for prophylactic anti-coagulation after hip fracture surgery do not reflect the latest international learning, specifically regarding optimal duration and the potential for hypercoagulability upon discontinuation in immobile, elderly patients.
Addressed to: National Institute of Health and Care Excellence
AI-generated concerns summaryThe coroner noted the absence of a vascular team at the County Hospital in Stafford, which meant urgent vascular opinions could not be obtained.
Addressed to: County Hospital Stafford