Browse 6,458 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 raised concerns regarding the clarity of consultant letters for GPs, leading to delays in prescribing, and the inability of specialists to issue initial prescriptions. Further concerns relate to the lack of real-time patient record access between different NHS Trusts.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in police officers' understanding of Mental Health Act powers and insufficient assessment of an individual's situation. Concerns were also raised regarding the fragmented sharing and visibility of healthcare records across multiple agencies.
Addressed to: London Ambulance Service NHS Trust; NHS England; One London Board; South London and Maudsley NHS Foundation Trust; College of Policing; Commissioner of the Metropolitan Police
AI-generated concerns summaryThe coroner raised concerns about significant delays in the Trust implementing identified changes to patient care, noting that a projected 12-month implementation period means risks of future deaths continue without interim measures.
Addressed to: Walsall Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted insufficient one-to-one nursing care due to understaffing and stretched resources, which contributed to the patient's fall and increases the probability of similar deaths.
Addressed to: Secretary of State for Health
AI-generated concerns summaryThe coroner notes there is no requirement for electric scooter riders to wear helmets, which creates a risk of death in collisions, even at lower speeds.
Addressed to: Secretary of State for Transport1.CORONERI am Miss Karen Boyle, Assistant Coroner for Nottingham and Nottinghamshire2.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
AI-generated concerns summaryThe coroner notes concerns regarding the delay in finalising and implementing an agreed, documented care pathway for patients with complex acute pancreatitis, which remains unshared across different hospital sites, posing a risk of future deaths.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryManual coding errors and insufficient feedback to GPs on referral urgency are concerns in the GP-Consultant booking chain. Additionally, the coroner highlights unintegrated IT systems for referrals and inconsistent reporting of incidental ED findings to GPs.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe standard £250 per week allowance for living expenses under Proceeds of Crime Act restraint orders has not been reviewed since 2009. The process to vary this figure is challenging and rarely qualifies for legal aid.
Addressed to: Attorney General of England and Wales and the Director of Public Prosecutions
AI-generated concerns summaryThe coroner noted that altered anatomy from previous gastric surgery was not recognized during nasogastric tube insertion. There were no national guidelines for such insertions in patients with previous gastric surgery, presenting a wider risk across NHS trusts.
Addressed to: NHS England1CORONER I am Miss Sarah Middleton, Assistant Coroner, for the Coroner Area of Northumberland. 2CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
AI-generated concerns summaryThe coroner noted that a recommendation made by the Professional Standards Department in a report dated 9 July 2025 may not have been actioned.
Addressed to: Chief Constable for the Gloucestershire Constabulary
AI-generated concerns summaryThe report identifies that a custody nurse did not record vital signs or clinical details before prescribing medication. It also notes Serco staff's delayed first aid response, insufficient training, and unclear emergency protocols, which impacted their ability to provide urgent care.
Addressed to: MPS; SERCO
AI-generated concerns summaryThe coroner raised concerns that the Public Emergency Call Service routing of calls for apparently deceased persons to the police risks losing critical minutes for life-saving treatment following ligature application. This delay could prevent intervention within the vital ten-minute window.
Addressed to: Department for Science, Innovation and Technology; National Police Chiefs’ Council
AI-generated concerns summaryA breach in a stone wall near County Bridge in Barnard Castle provides unrestricted and unguarded access from a public area to a 9-metre drop onto rocks and the River Tees.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted the high prevalence of drug and alcohol abuse, rough sleeping, and criminal activities in Pearson Park, which places vulnerable individuals at high risk.
Addressed to: Chief Constable of Humberside Police
AI-generated concerns summaryThe coroner raised concerns regarding significant delays and inadequate quality in the triage of patient referrals. There were also issues with non-clinicians undertaking complex risk assessments and subsequent delays in patients being seen by qualified clinicians, pointing to potential wider training deficiencies.
Addressed to: Kent & Medway NHS Mental Health Trust
AI-generated concerns summaryThe coroner noted that fire safety regulations do not mandate personal emergency evacuation plans or standardised staff training for individual flats in residential care. Additionally, Fire Risk Assessments may not adequately account for the specific risks posed by vulnerable residents.
Addressed to: Care Quality Commission; Local Government Association; Minister for Housing Communities and Local Government; National Fire Chiefs Council
AI-generated concerns summaryThe coroner noted concerns that the "Right care right person" (RCRP) policy is being implemented too rigidly, which reduces the scope for call handlers to escalate calls for senior professional judgment, particularly when other professionals express a concern for life and limb.
Addressed to: Cheshire Police
AI-generated concerns summaryPatient observations on Ellis Ward are not consistently carried out in accordance with the Trust's policy, which requires an attempt at engagement. Written logs and staff evidence indicate observations are often a headcount without engagement.
Addressed to: South West London and St George’s Mental Health NHS Trust
AI-generated concerns summaryConcerns were raised that Flow Coordinators responsible for patient discharge arrangements are not consistently briefed on patient vulnerabilities, potentially leading to unsuitable travel arrangements.
Addressed to: North Cumbria Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner highlighted the need for guidance to support an interventionalist, supervisory role with appropriate training for doctors working in care homes when managing pressure sores.
Addressed to: Department of Health and Social Care (changed to NHS England)