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 noted limited access for police officers to immediate, qualified mental health advice and clinical records when responding to crises, due to the withdrawal of triage support and the delayed implementation of a replacement service.
Addressed to: South Wales Police
AI-generated concerns summaryA matt black, locked steel barrier on Cheadle Old Road Edgeley, a legitimate right of way, is difficult to see in low light conditions and poses a risk of serious injury or death to users.
Addressed to: Department for Transport; Stockport Metropolitan Borough Council
AI-generated concerns summaryThe coroner raised concerns about road safety at a collision location, specifically regarding the speed limit, limited visibility for tractor drivers, and evidence of speeding. Additionally, Council recommendations for improvements at the site have not been implemented.
Addressed to: Cornwall Council; Little Trethew Horningtops
AI-generated concerns summaryThe absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital contributes to delays in diagnosis and necessitates switching treatment centres, which is inconsistent with providing a full cardiology service.
Addressed to: Department of Health and Social Care; NHS England; Stepping Hill Hospital
AI-generated concerns summaryThe coroner noted concerns about clinical staff's knowledge and clarity of the Acute Abdominal Pain Pathway, and that the hospital's Serious Incident process did not incorporate family information. A documented process for patients who self-discharge was also lacking.
Addressed to: East Kent Hospitals University NHS Foundation Trust; National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThe coroner identified gaps in medical records, including incomplete entries by junior doctors after ward rounds. Concerns were also raised about the adequacy of discussions regarding treatment options and consent with the patient's family prior to surgery.
Addressed to: University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a full Mental Health Act assessment and inadequate risk assessments for a person displaying erratic behaviour and experiencing a mental health crisis before discharge from hospital or release from custody.
Addressed to: Midlands Partnership Trust; West Midlands Police
AI-generated concerns summaryThe coroner identified numerous failed attempts by medical services to contact Ms Kelly for reviews and delayed allocation of a new care coordinator. Despite these unsuccessful contacts, a welfare check was not initiated until neighbours raised concerns.
Addressed to: Gray’s Inn Road Medical Centre; North London Mental Health Partnership; South Camden Rehabilitation of Recovery Team
AI-generated concerns summaryThe coroner noted that a lack of mental health hospital beds meant Ms Petit was denied optimal treatment. This shortage also resulted in patients requiring detention being held in general hospitals without a legal section in place.
Addressed to: NHS England; Surrey and Borders Partnership Trust
AI-generated concerns summaryThe coroner noted concerns that the 'Consultant of the Week' model does not allocate a named consultant to complex transplant patients, which can affect continuity of care and a longer-term view of their post-operative recovery.
Addressed to: Manchester University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of overall consultant responsibility for a medical outlier patient and no Trust policy to address this. Concerns also included insufficient monitoring of electrolytes and fluid balance, and outdated care plans due to routine copying and pasting.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryPolice mental health training and awareness of statutory powers/resources were found insufficient. Concerns also included untimely information sharing between police and mental health services, and the lack of policy for a new joint working system.
Addressed to: Sussex Partnership NHS Foundation Trust; Sussex Police
AI-generated concerns summaryThe coroner identified significant delays in discharging patients to suitable care homes, causing inappropriate care and acute bed shortages. Issues included poor communication between hospital and community teams on care plans, and limited access to community wound care.
Addressed to: Care Quality Commission; Department of Health and Social Care; Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner identified that despite falls risk assessments, no documented falls prevention measures were implemented for Ms. Maycroft in the hospital's Emergency Department and Acute Frailty Unit, and there was no evidence that these issues have been addressed.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inadequate social care, community hospital, and primary healthcare provision for discharges in Cornwall contributing to ambulance delays. The report notes an absence of a single organisation responsible for ensuring sufficient social care or for patient safety risk from these delays.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified limitations in the DVLA's medical review process, noting insufficient encouragement for doctors to obtain comprehensive medical histories and a reliance on tick-box forms for GPs. Concerns were also raised about the lack of verification for applicant self-declarations and the absence of an audit procedure for licensing decisions.
Addressed to: Driver and Vehicle Licensing Agency
AI-generated concerns summaryConcerns were raised regarding a lift's uncontrolled movement device, which was unintentionally activated and could not be reset, leading to entrapment. This required Fire & Rescue Service intervention and caused a delay that could seriously affect future patients.
Addressed to: Schindler Ltd
AI-generated concerns summaryThe coroner noted concerns that a company's risk assessment concluded lifeguards were not reasonably practicable, despite a Health & Safety officer deeming compliance with minimum standards borderline and observing similar companies provided lifeguards.
Addressed to: Atlantic Reach Limited
AI-generated concerns summaryThe coroner raised concerns regarding the rapid discharge of an exhausted mother just four hours after a prolonged labour and induced delivery, suggesting that more rest in hospital might have prevented the baby's death.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the agreed action plan had led to improvements in care.
Addressed to: Barking, Havering & Redbridge University Trust