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 that other properties in the local area have walls built with unsafe dimensions, similar to one that collapsed during Storm Eunice, which creates a risk of further collapses and future deaths in strong storms.
Addressed to: Eastleigh Borough Council; Southampton City Council
AI-generated concerns summaryThe coroner noted an assumption was made which prevented any exploration of whether an alternative action was possible.
Addressed to: Radis Community Care
AI-generated concerns summaryThe coroner expressed concern that current legislation does not restrict the number of young passengers carried by young and newly qualified drivers, which increases the risk of collisions and future deaths.
Addressed to: Clough Williams-Ellis Trust; Cyngor Gwynedd Council Landowner; Department for Transport
AI-generated concerns summaryConcerns were raised regarding a mental health assistant practitioner's limited training, insufficient understanding of risk, and unclear supervision. The report also noted inadequate patient triage, challenges with telephone assessments, and poor documentation.
Addressed to: Department of Health and Social Care; GTD Healthcare
AI-generated concerns summaryThe coroner identified that the risks of reintroducing opioid painkillers to a patient with a history of opioid addiction were not considered or monitored, highlighting the need for careful rationale and monitoring in such cases.
Addressed to: Greater Manchester Integrated Care Board; Royal College of General Practitioners
AI-generated concerns summaryThe coroner noted a clear risk of future deaths if agency staff at Darnell Grange are not provided with home-specific training or policies, specifically regarding the protocol for moving residents after a fall.
Addressed to: Darnell Grange Nursing Home
AI-generated concerns summaryThe coroner noted a lack of understanding among staff in providing first aid to unresponsive residents and insufficient knowledge and embedding of the new policy for escalating issues.
Addressed to: Caremark (Chiltern & Tree Rivers)
AI-generated concerns summaryThe electronic patient enquiry service did not ensure patient information reached GPs. A persistent hoarse voice was also not consistently recognised as a laryngeal cancer red flag by healthcare professionals.
Addressed to: Department of Health and Social Care; Derby and Derbyshire Integrated Care Board
AI-generated concerns summaryThe coroner noted a lack of liaison between care teams and an absence of specific consideration within the Trust's SOP and national guidelines for patients with HbSS undergoing liver biopsy, including post-operative monitoring.
Addressed to: Homerton Healthcare NHS Foundation Trust; British Society of Gastroenterology; Royal College of Pathology; Royal College of Radiologists
AI-generated concerns summaryThe coroner raised concerns about the ongoing practice of treating patients in undesignated hospital corridors when the Emergency Department exceeds capacity, leading to a lack of privacy, toilet facilities, and confidentiality for patients.
Addressed to: Department of Health and Social Care; NHS England & NHS Improvement; University Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of guidance for pharmacists on dispensing medication to cognitively impaired patients living together, particularly concerning the use of identical dosset boxes. There were no policies for providing distinct medication packaging in such circumstances.
Addressed to: Berkshire Integrated Care Board; Community Pharmacy England; General Pharmaceutical Council; Local Pharmacy Commission; Medicines and Healthcare Products Regulatory Agency; National Pharmaceutical Association; NHS Specialist Pharmacy Service; Slough Pharmacy
AI-generated concerns summaryThe coroner identified a delayed diagnosis of abdominal pathology from a CT scan that contributed to death. Concerns include significant delays by the Trust in investigating the reporting error, assessing harm, disclosing it to the family and coroner, and evidencing learning.
Addressed to: York & Scarborough Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell observation panels to be obscured, and there is insufficient guidance on entering cells during emergencies.
Addressed to: HM Prison and Probation Service; Ministry of Justice
AI-generated concerns summaryThe coroner identified inadequate assessment and practical advice during a crisis call by Tees Esk and Wear Valley NHS FT. There were also multiple lapses in basic nursing care at York & Scarborough Teaching Hospitals NHS FT, including nutritional management and a delayed response to choking.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust; York and Scarborough Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the robustness of procedures for clients being considered by Mind, and the lack of transparent processes for patients returning from Mind to the Neighbourhood Mental Health Team.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted concerns that the alarm system allows staff to silence alarms before checking patients during night shifts, leaving patients potentially unmonitored. Infrequent monitor checks further increase the risk of patients remaining unmonitored for significant periods.
Addressed to: Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner identified insufficient mental health, alcoholism, and addiction support, treatment, and therapy for veterans while serving, during intensive combat training, and after release. This includes limited availability of resources, leading to significant wait times for ex-veterans.
Addressed to: Ministry of Defence
AI-generated concerns summaryInconsistent night monitoring, including reliance on an inadequate video monitor instead of direct observation, was noted. Concerns also included incomplete medical records, a lack of regular PEWS assessments, and insufficient specialist paediatric neurological oversight.
Addressed to: Care Quality Commission; Department of Health and Social Care; NHS England; Tadworth Children’s Trust
AI-generated concerns summaryUnchecked online availability of lethal Sodium Nitrite, a lack of awareness among suppliers about its misuse, and the presence of online guidance on its use for suicide without adequate removal systems.
Addressed to: Department for Science Innovation and Technology; Department of Health and Social Care; National Suicide Prevention Strategy Advisory Group
AI-generated concerns summaryInsufficient psychiatric inpatient beds for children in Surrey, noting a new unit's limited capacity and scope. The new risk assessment system also lacks a clear suicide risk alert on medical records, potentially leading clinicians to miss vital information.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust