Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner notes a widespread misunderstanding among schools and colleges that £6,000 must be spent on a child’s Special Educational Needs before applying for a statutory assessment. This delay in assessment and early support may increase the risk of mental health difficulties and suicidality developing.
Addressed to: Department for Education; Surrey County Council
AI-generated concerns summaryA registered nurse and care coordinator were unaware of urgent mental health referrals for Oliver due to information not being highlighted on his medical record. This led to a low priority assessment and delay in his mental health care appointment.
Addressed to: Midlands Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns that surgeons performing Periacetabular Osteotomy (PAO) procedures often engage in infrequent practice, and the voluntary specialist register does not flag these cases. Uncertainty exists if trusts recognise PAO as distinct.
Addressed to: NHS England
AI-generated concerns summaryThe high-level intermittent observation system failed to prevent Florence's suicide and requires fundamental review. Separately, the oxygen bottle used during resuscitation ran out of oxygen.
Addressed to: Central North West London NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that many children do not receive vital water safety education in school, resulting in insufficient awareness of water dangers. This situation is compounded by reduced access to swimming pools and the voluntary nature of supplementary water safety initiatives.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner raises concerns that an Authorised Mental Health Professional (AMHP) was unable to make direct referrals to the Crisis Resolution and Home Treatment Team, causing a delay in the individual receiving immediate mental health support.
Addressed to: Department of Health and Social Care; Norfolk and Suffolk NHS Foundation Trust; Suffolk County Council
AI-generated concerns summaryThe coroner noted inadequate induction for a long-term locum doctor regarding specific cardiology policies. There were also missed opportunities to identify incorrect patient medication, even after the oversight was recognised by staff.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner identified significant omissions in Mr. Agius's medical record documentation, including an incomplete risk assessment following a crisis intervention. There was also no evidence of the Trust implementing new national training for mental health risk assessments.
Addressed to: North East London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of a clear escalation route when prison healthcare staff challenged hospital patient discharges, and no national guidance on returning prisoners to custody if healthcare concerns were unaddressed by consultants.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns regarding the existence and use of gas piston bed mechanisms, noting that their failure presents a risk to life.
Addressed to: Department for Business and Trade; Office for Product Safety and Standards
AI-generated concerns summaryThe coroner noted a lack of communication and coordination between various health services regarding the individual's epilepsy and psychotic symptoms, leading to significant delays in treatment and rejected referrals. This included insufficient information sharing and uncoordinated medication reviews.
Addressed to: Sheffield Health and Social Care NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about continuing ambulance handover and response delays, which are linked to inadequate social care and community hospital provision causing delayed discharges. There is no single organisation responsible for ensuring sufficient social care to prevent these delays or for overarching patient safety risk from ambulance delays.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of specialist healthcare provision and commissioned services in England for patients with severe ME, alongside insufficient funding for ME/CFS research and limited medical training. Furthermore, 2021 NICE guidelines provide no detailed guidance on managing severe ME at home or in the community.
Addressed to: Department of Health and Social Care; Medical Research Council; Medical Schools Council; National Institute for Health and Care Excellence; National Institute for Health care and Research; NHS England
AI-generated concerns summaryThe coroner identified potential issues with poor record keeping and raised concerns regarding communication between professionals within the Trust and with patients.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that bank staff could not access patient notes before assessments and different NHS Trusts were unable to access patient notes due to incompatible computer systems.
Addressed to: Derby and Burton Hospital; NHS England; Royal Stoke University Hospital
AI-generated concerns summaryA&E management lacked timely alerts for prolonged patient stays and adequate assessment of complex care needs. Concerns also related to insufficient nurse knowledge of basic asthma assessments and a failure to escalate problems to senior nursing staff.
Addressed to: Lancashire Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted insufficient follow-up by an occupational therapist and social worker regarding a fire safety visit's outcome. There was also a lack of communication from the London Fire Brigade, which shared findings only with the vulnerable individual and did not provide the written risk assessment to her carers or …
Addressed to: London Borough of Newham; London Fire Brigade
AI-generated concerns summaryThe coroner noted significant deviations from the Manchester Triage System and delays in senior doctors recording patient findings in Emergency Departments. This pressure, the coroner highlighted, reduces the ability to identify atypical or life-threatening illnesses.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in police training for assessing mental health calls, and issues with timely notification of Mental Health Act admissions to carers and access to independent advocates. Further concerns included a lack of connectivity between UK and international mental health services for repatriated patients and inadequate inter-agency communication …
Addressed to: Care Quality Commission; Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust; Greater Manchester Police; Home Office; NHS England; North West Ambulance Service; College of Policing; Trafford Council
AI-generated concerns summaryThe coroner noted inadequate robustness in prisoner welfare checks, citing insufficient time for staff, unreliable signs of life, and gaps in training on how to perform checks and record positive responses.
Addressed to: HMP Wandsworth