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 noted that fall prevention measures, such as fencing and barriers, were only partially implemented on one level of the car park, where Mrs Gawthorpe fell. At this location, the parapet wall remained easily climbable.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner noted a lack of real-time information sharing between the cafe71 service and the mental health team, meaning cafe71 staff lack access to patient background and risk factors, and mental health teams are not notified of contacts.
Addressed to: Cheshire and Wirral Partnership NHS Foundation Trust; Spider Project Café 71; West Cheshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified a lack of clear systems for quality checks on unwell residents, limited documentation, and an unclear escalation process not understood by staff.
Addressed to: Care Quality Commission; Lakes Care Centre
AI-generated concerns summaryThe coroner noted a lack of understanding among front-line officers regarding controlling and coercive behaviour, the link between domestic abuse and suicide, and the correct application of Domestic Violence Protection Notices (DVPNs) and referrals to DAISU.
Addressed to: Hertfordshire Constabulary
AI-generated concerns summaryThe coroner noted persistently long Category 2 ambulance response times by the East of England Ambulance Service, which consistently exceed national targets, and that actions taken to address this issue have been ineffective.
Addressed to: Department of Health and Social Care; East of England Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a child-specific screening tool for pulmonary thromboembolism in the UK and a lack of NICE guidance for children on venous thromboembolic diseases. This may disadvantage clinicians in diagnosing and treating the condition in children due to a lack of comparable resources.
Addressed to: National Institute for Health and Care Excellence; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted a lack of joint multi-disciplinary approach to complex medical care, with inadequate documentation of key decisions like antibiotic withholding and ICU admission. Concerns were also raised about inconsistent adherence to referral policies and unclear responsibility for care continuity.
Addressed to: Department of Health and Social Care; Tameside General Hospital
AI-generated concerns summaryThe coroner identified issues with documents bearing signatures that witnesses denied, retrospective alteration of records, and incomplete disclosure of documents which hampered the investigation and risk accurate record-keeping.
Addressed to: HMP Norwich
AI-generated concerns summaryThe coroner noted a delay in accessing mental health treatment appointments after a referral to the Community Treatment Team and raised concerns regarding the lack of clear record-keeping for a missed appointment.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of designated pedestrian pathways, road markings, and warning signs for pedestrians on a service road shared with vehicles. Obstructions in the road reduced visibility and impeded emergency service access, compounded by the absence of a speed limit.
Addressed to: Walsall MBC
AI-generated concerns summaryThe coroner noted concerns regarding the robustness of post-discharge care coordination for mental health patients, particularly the reliance on telephone appointments, thresholds for MDT discussions, and insufficient routes for family input. There were also concerns about communication with primary care.
Addressed to: Berkshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a significant delay in ambulance response for a Category 2 call, which took almost 5 hours instead of the target 40 minutes. This was attributed to prolonged patient offloading times at hospitals, tying up ambulance resources.
Addressed to: Department of Health of Social Care; NHS England; West Yorkshire Integrated Care Board
AI-generated concerns summaryThe coroner identified that a welfare sheet for monitoring prisoner health lacked clear purpose and completion guidance. Entries by prison staff were not consistently made known to medical staff, and its operation had not been jointly considered by prison and healthcare.
Addressed to: HMP Garth
AI-generated concerns summaryThe coroner raises concerns about a lack of clarity for CAMHS teams, patients, and parents regarding national referral mechanisms for gender services and the resources available to provide mental health support for young people on waiting lists. This situation may lead to extended wait times and potential risks while awaiting …
Addressed to: National Referral Support Service; NHS England
AI-generated concerns summaryThe coroner noted concerns regarding general medical knowledge related to the management of neuroleptic malignant syndrome, the role of Dantrolene in pulmonary oedema, its interaction with Labetalol, and the diagnosis of serotonin syndrome risks during anaesthesia.
Addressed to: Department of Health and Social Care; Royal Colleges of Anaesthetists
AI-generated concerns summaryMidwives and a doctor were unaware of the potential for hyponatremia in birthing women. Additionally, fluid input and output were not accurately recorded during labour, despite encouragement for increased fluid intake.
Addressed to: Department of Health and Social Care; NHS Sussex Integrated Care Board; Nursing and Midwifery Council; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted that current policies for VTE risk assessment do not require it for patients during long waits in emergency departments. The 24-hour assessment period's start point is unclear, beginning only upon ward admission rather than ED attendance.
Addressed to: Frimley Health NHS Foundation Trust; National Institute of Clinical Excellence; NHS England
AI-generated concerns summaryThe coroner identified a lack of independent investigations for deaths of patients detained under the Mental Health Act, which hinders effective oversight and learning. Current investigations are also ineffective due to a lack of trained investigators or insufficient understanding of complex health processes.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified deficiencies in mental health act assessments by Approved Mental Health Practitioners (AMPHs), including insufficient information gathering and non-compliance with legal requirements. AMPH responses to Nearest Relative requests also did not always meet statutory duties.
Addressed to: City and County of Swansea; NHS Wales; Swansea Bay University Health Board
AI-generated concerns summaryUK Border Force lacks legal powers to seize certain consignments for ending life, with holding limited to 30 days. There is no national guidance or joint protocols for police and Border Force on managing these, or for alerting local police.
Addressed to: Home Office; National Police Chiefs Council