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 summaryCritical suicide risk information was not consistently or timely recorded, and the coroner questioned the sufficiency of existing policy. Concerns were also raised about new guidance for informal patient transport, which lacks specific questions for adequate risk assessment.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a nationwide lack of understanding among doctors regarding the signs, symptoms, and risks of air embolism, which is not routinely taught. This knowledge gap can lead to delayed recognition and treatment, increasing the risk of adverse outcomes.
Addressed to: Royal College of Anaesthetists; Royal College of Emergency Medicine; Royal College of Physicians; Royal College of Surgeons; Royal Society of Medicine
AI-generated concerns summaryThe coroner noted a lack of clarity regarding the responsibility for providing mental health treatment to terminally ill patients, as care was passed between multiple teams. This raises concerns that future patients may not receive necessary mental health support, leading to potential crises.
Addressed to: North East and North Cumbria Integrated Care Board
AI-generated concerns summaryThe coroner noted a lack of clear national guidance for clinicians on pausing DOACs, leading to inconsistent practice, and insufficient communication and action on time-critical medical directions, potentially due to issues with continuity of care and computerised records.
Addressed to: Department of Health/Secretary of State; NHS England; NHS Improvement; NICE; Warwick Hospital
AI-generated concerns summaryA Mental Health Treatment Requirement (MHTR) was not communicated to a receiving Trust when a patient's care transferred, meaning the order was not administered. The coroner notes that probation should ensure all services are aware of and properly administer MHTRs.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted the ongoing local and national lack of suitable placements for high-risk children with complex mental health needs.
Addressed to: Department for Education; Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified gaps in the regulation of Physician Associates (PAs), noting the absence of a mandatory national framework for their training, supervision, and competency. The report also raises concerns about limited understanding of the PA role and a competency sign-off that omitted broader patient care aspects like consent.
Addressed to: Department of Health and Social Care; Faculty of Physician Associates; General Medical Council
AI-generated concerns summaryThe coroner noted significant and ongoing crowding in the Emergency Department at Royal Cornwall Hospital, leading to extensive patient waiting times for beds or transport after being ready for discharge. These pressures were identified as having the potential to affect future patient care.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a delay in a welfare check due to confusion between Surrey Police and the Metropolitan Police, raising concerns that such communication failures could result in avoidable fatalities in future cases.
Addressed to: Metropolitan Police Service; Surrey Police
AI-generated concerns summaryThe coroner noted that no emergency ambulance resources were available, and the ambulance service was not meeting response standards due to demand exceeding resources. This was exacerbated by lengthy hospital handover times at Accident and Emergency departments, which continue to delay ambulances.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that paramedics do not have access to alternative forms of analgesia, such as nasal or buccal morphine, which could facilitate pre-hospital treatment or faster patient extraction.
Addressed to: Department of Health and Social Care; Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner identified insufficient driver training for US diplomatic personnel arriving in the UK regarding road signs and rules. Concerns were also raised about discrepancies between reported and actual content of new driver safety briefings concerning wrong-way driving risks.
Addressed to: Foreign, Commonwealth & Development Office; Ministry of Defence; Ministry of Defence Police
AI-generated concerns summaryThe coroner noted that Mrs Hammon’s rising CRP was not identified by the clinical team, potentially reflecting a wider lack of knowledge. Additionally, fluid charts were inadequate and Early Warning Scores were often incomplete.
Addressed to: Ashford and St. Peter’s Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified significant understaffing within the Probation Service, which impacted assessment quality and staff supervision. Concerns were also raised about a poor understanding and application of risk assessment, a lack of appropriate training, and issues with the OASYS tool and alert systems.
Addressed to: HM Prisons and Probation Service; Ministry of Justice; Redbridge Council; Home Office; Metropolitan Police Service
AI-generated concerns summaryThe coroner noted ongoing and unimproved delays in ambulance response times for emergency calls, specifically highlighting the impact of slow release of ambulances from acute hospitals.
Addressed to: Cabinet Secretary Health Social Care & Welsh Language
AI-generated concerns summaryThe coroner noted that aripiprazole, prescribed as a prophylactic monotherapy for bipolar disorder, was not considered effective against the depressive polarity, potentially leaving the patient unprotected from depressive relapse due to misleading clinical guidance.
Addressed to: BMJ Group; National Institute for Health and Clinical Practice; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner raises concerns about Cambridgeshire County Council's decision not to reduce the 60 mph speed limit on a dangerous road with an uneven surface, noting insufficient inspections, slow remedial actions, and a lack of clear response to local safety recommendations.
Addressed to: Cambridgeshire County Council; Department for Transport
AI-generated concerns summaryThe coroner identified inadequate risk assessment and safety planning before discharge from hospital and community mental health services. Concerns included an over-reliance on self-reporting, insufficient information gathering, and staff understanding of assessment processes.
Addressed to: Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryThe coroner expressed concern about the lack of safety measures where a well-used track meets the A460 Eastern Way, noting no warnings for drivers or pedestrians, no prevention for pedestrians entering the road, and no safe crossing point.
Addressed to: Road Safety Management Staffordshire County Council
AI-generated concerns summaryThe Trust failed to prevent a predictable and avoidable fall that resulted in death. The Trust's governance systems did not identify or reflect upon care failings during the subsequent After Action Review, preventing remediation of contributing factors.
Addressed to: Barts Health Foundation Trust; Department of Health and Social Care