Browse 6,458 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryA mandatory mental health assessment for a prisoner transferred to the Segregation Unit was not completed within the required 24-hour timeframe. The report notes this breach of a standing instruction.
Addressed to: Practice Plus Group; Minstry of Justice
AI-generated concerns summaryThe coroner identified a lack of 7-day mental health support at HMP Haverigg and noted that limited staff means prisoners in crisis may be transferred, which could incentivise them to understate their self-harm risk.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns about the lack of clear consent forms and Multi-Disciplinary Team meetings to ensure patients understand the risks of unsafe home births. It was also noted that the term "Out of Guidance" may not adequately convey the gravity of such decisions.
Addressed to: Department of Health and Social Care; National Institute for Health and care Excellence; NHS England
AI-generated concerns summaryThe coroner expresses concern over potential missed opportunities by the IOPC and Metropolitan Police Service to identify Rebekah as a victim of domestic abuse and coercive control, hindering her protection. This involved a history of unexplained injuries and her husband's misuse of police powers.
Addressed to: Home Office; Independent Office for Police Complaints; Metropolitan Police Service; Secretary of State for Justice
AI-generated concerns summaryConcerns included inadequate emergency planning, insufficient staff training in CPR and airway management, and the absence of a defibrillator on site, leading to staff feeling unprepared for medical emergencies.
Addressed to: Choice Support; NHS England; NHS South West London ICB
AI-generated concerns summaryThe coroner identified gaps in Adult Social Care Services' ability to identify and monitor adults at risk of neglect who are resistant to engagement and assessment, suggesting a need for a register and unannounced visits.
Addressed to: Cardiff Citu Council
AI-generated concerns summaryMental health practitioners in Cwm Taf Morgannwg University Health Board lack immediate access to comprehensive patient records, particularly when care spans different localities. This raises concerns about the potential for incomplete or insufficient assessments for individuals in crisis.
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryThe coroner noted a lack of national guidance for cross-Trust transfers of complex cases, particularly for patients with co-existing eating disorders and complex emotional needs. There is also no national specified treatment pathway for individuals presenting with these co-existing difficulties, impacting how services are commissioned and managed.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted that mail order businesses may be unable to perform statutory checks for suspicious transactions involving reportable poisons. Additionally, eBay's Hazardous Materials Policy does not list concentrated reportable poisons as prohibited items.
Addressed to: Ebay
AI-generated concerns summaryThe coroner raised concerns that a former company's website contains text referring to a method of self-destruction and linking to suicide websites, which could assist individuals inclined towards deliberate self-harm.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner raises concerns that a strict 18th birthday cut-off for commissioning mental health provision for children and adolescents could be prejudicial to their mental health in certain circumstances.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted an insufficiency in the NHS Pathway system's questions to correctly identify the seriousness of an uncontrolled bleed, as there is no specific question about whether a bleed is controlled. This could lead to incorrect call categorisation and delayed treatment for serious events.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner identified inadequate observation levels for Mr McKinlay relative to his falls risk assessment and care plan. There was no evidence of investigations into multiple falls at two hospitals, raising concerns about learning and improvement.
Addressed to: University Hospitals of Birmingham NHS Foundation Trust
AI-generated concerns summaryInsufficient focus on authorising patient trips out, with informality, absent checklists, and inadequate auditing. Concerns included nurses not reading notes, incomplete records, unclear safety planning, and lack of family involvement in risk management.
Addressed to: 1 Sussex Partnership NHS Foundation Trust1.CORONERI am Nick ARMSTRONG, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove2.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and; Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that an occupational health referral was not made, which would have triggered a stress risk assessment and support. Concerns were also raised about staff knowledge and training regarding occupational health referral procedures and available support.
Addressed to: Unilver Plc
AI-generated concerns summaryThe coroner noted the absence of electronic safeguards for observation recording and a paediatric pathway not aligned with national guidance. Concerns included insufficient mechanisms for assessing neurodivergent patients and parents, and critical GP information not transferring effectively to the hospital.
Addressed to: College of General Practitioners; NHS England, George Eliot Hospital NHS Trust
AI-generated concerns summaryThe coroner noted insufficient training and awareness for volunteer divers regarding medical requirements and immersion pulmonary oedema. There were also concerns about the clarity and potential misinterpretation of HSE diving regulations and guidance concerning volunteers.
Addressed to: British Diving Safety Group; Health and Safety Executive
AI-generated concerns summaryThe coroner raised concerns regarding the lack of local services for co-occurring mental health and substance misuse conditions, the ease of access to large quantities of alcohol via online delivery, and the inability of drug and alcohol service professionals to access mental health records within the same NHS Trust.
Addressed to: Department of Health and Social Health
AI-generated concerns summaryNHS England guidance for managing alleged staff perpetrators of sexual misconduct lacks advice on risk assessments, prompt police notification, and decisions regarding suspension and access to fatal drugs.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that nursing staff were unaware of s17 leave conditions, leading to inappropriate leave grants. Concerns were also raised about staff ability to manage cardiac arrests effectively on acute mental health wards, including poor CPR and delayed emergency calls.
Addressed to: Sussex Partnership Foundation Trust