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 summaryThe coroner identified a lack of clear protocols for escalating a deteriorating patient and ineffective communication between clinical staff, which led to a delay in a CT scan request being acted upon. There were also no clear procedures or expectations for record keeping, meaning plans were not immediately available for …
Addressed to: HCA Healthcare UK
AI-generated concerns summaryCoroner noted mental health practitioners faced difficulties accessing full clinical records, including those from NHS England, and a lack of clinical psychologists for direct assessment and treatment in inpatient and home treatment teams.
Addressed to: Cwm Taf Morgannwg University Health Board; Welsh Government
AI-generated concerns summaryThe deceased had a responsible position within Healthcare, but no further details are provided in the concerns text.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted continued late discharges for patients unable to manage independently, with the ambulance service unaware of policy changes. Delays and factual inaccuracies in a Serious Incident Review were also identified.
Addressed to: East Midlands Ambulance Service; Manchester City Council; Manchester University NHS Foundation Trust
AI-generated concerns summaryThe deceased was able to use a petrol pump without a required motor vehicle or authorised container, as no staff were present to approve or deny access, and approval was automatic following payment at the pump.
Addressed to: Tesco Stores Limited
AI-generated concerns summaryMental health professionals in the Emergency Operations Centres lack access to patient mental health records held on SystmOne, despite EMAS having access to GP records on the same system. This information could be crucial for triage and dispatch of ambulance resources, particularly for patients with a history of suicidal ideation.
Addressed to: East Midlands Ambulance Service NHS Trust; Northamptonshire Integrated Care Board
AI-generated concerns summaryThe coroner raises concerns that current British Standards for window restrictors in residential care homes are inadequate for preventing deliberate attempts to open windows, and operators are generally unaware of more robust guidance. There is a need for updated guidance and a review of the British Standard for these settings.
Addressed to: British Standards Institute; Care Quality Commission; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of processes to ensure prompt medical attention for residents and full utilisation of care notes for recording injuries and incidents. Concerns were also raised regarding the absence of falls risk assessments on admission.
Addressed to: Deerlands Residential Home
AI-generated concerns summaryThe coroner noted a culture of poor management and institutional defensiveness within the MPS, where junior officers feared speaking out and senior management was unwilling to listen independently to concerns, despite changes in policy.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryAgencies had a limited understanding of how coercive and controlling behaviours impact mental health, did not effectively listen to children's concerns, and failed to recognise the victim's additional vulnerability due to physical health and dependency on the perpetrator.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner identified gaps in mental health care for patients held under Section 5(2) MHA on acute wards, noting no allocated Responsible Clinician and lack of mental health liaison team attendance for risk assessment. Concerns also included acute staff's lack of specialist training, confusion over 1:1 observation policy, and no …
Addressed to: Essex Partnership University NHS Trust; Mid & South Essex NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner noted an excessive gap in ACCT observations and risks from fixed shower rails as ligature points. Concerns were also raised about staff training on personality disorders and the suitability of cells for vulnerable prisoners subject to cellular confinement.
Addressed to: Ministry of Justice
AI-generated concerns summaryConcerns included insufficient consideration of the patient's complex trauma and the complexities of foreign body removal, alongside a lack of urgency in recognising and investigating her deteriorating clinical condition.
Addressed to: East Suffolk and North Essex NHS Foundation Trust; NHS England
AI-generated concerns summaryInformation about previous suicidal ideation was not shared from the Independent Visitor to the foster carer, and Calderdale Council could not provide details on training or escalation procedures for mental health disclosures.
Addressed to: Calderdale Council
AI-generated concerns summaryThe coroner noted a narrow focus in the Trust's review process and a lack of clear guidance for communication between specialisms, contextualising test results, and senior review of incongruous diagnostic findings. Concerns were also raised about the absence of authoritative national guidelines for ECG interpretation.
Addressed to: Manchester University NHS Foundation Trust; National Institution for Health and Care Excellence
AI-generated concerns summaryThe coroner raised concerns about insufficient staffing levels in the Community Mental Health Team, which caused delays in patient referrals and assessments. There were also concerns regarding the delayed implementation of an action plan to establish clear clinical standards for completing early warning signs.
Addressed to: Birmingham and Solihull Mental Health Foundation Trust
Addressed to: Department of Health and Social Care; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryAbnormal blood results telephoned to the emergency department were not documented or actioned for many hours. There is no electronic system for laboratories to send urgent results with an alert, relying instead on person-to-person communication.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe GP practice lacked policies for long-term opioid prescriptions, including patient agreements on treatment strategy and warning flags for addiction risk after three months. There was also no policy regarding the co-prescription of opioids and benzodiazepines.
Addressed to: Petroc GP Group Practice
AI-generated concerns summaryThe HIAB crane lacked an audible sound during operation, raising concerns about inadvertent remote control use. The managing director subsequently requested design changes for an audible sound and a two-handed remote operation.
Addressed to: ALLMI