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 gap in commissioning and support for individuals aged 17 with sensory needs, as an occupational therapy referral was rejected due to age and adult services would not accept until 18.
Addressed to: Cheshire and Merseyside Integrated Care Board
AI-generated concerns summaryThe coroner noted that ambulance response targets are not consistently met due to hospital bed blocking, caused by a lack of community care packages for discharged patients. This leads to ambulance delays in the community, increasing the risk of death.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe report describes Rachel's informal admission to the Woodlands mental health ward in Ipswich on March 6th, 2017, following a significant overdose.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of documentation for the removal of Ash's ligature risk assessment and a policy gap for "ad hoc" waking night cover, which led to an 11-hour period without checks. Concerns were also noted regarding insufficient communication of historic risks between care homes.
Addressed to: United Children’s Services
AI-generated concerns summaryThe coroner raises concerns about the ability of staff supervising S.17 leave to identify serious incidents requiring intervention, and the Trust's capacity to identify matters needing full governance investigation.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about significant staffing issues causing delays in patient treatment and a risk of future avoidable deaths. The report notes insufficient cohesive forward thinking or planning to address these ongoing challenges.
Addressed to: Department of Health and Social Care; NHS Birmingham and Solihull Integrated Care Board; NHS England; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an absence of a local policy governing the use of handcuffs when executing an arrest warrant.
Addressed to: College of Policing; Greater Manchester Police; Independent Office for Police Conduct
AI-generated concerns summaryThe coroner noted insufficient engagement by C&I services with Mr Ladapo's family, and a psychiatrist omitted to ask about suicidal ideation during consultations despite noted deterioration. This indicates a gap in staff awareness regarding the importance of exploring suicidal feelings.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns about the practice of creating hospital discharge summaries prematurely with speculative patient information and the lack of a system to prevent incomplete documents from being marked as complete and sent to GPs.
Addressed to: Blackpool Teaching Hospital NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner expressed concern about the safety of bin lorry lift systems, noting that thousands of older design vehicles remain in circulation with slow uptake of safety modifications, posing a risk of inadvertent lifting of people into the hopper.
Addressed to: Dennis Eagle Ltd
AI-generated concerns summaryThe coroner noted that the student accommodation window from which Chenyang jumped lacked sufficient window restrictors, contrary to known risks and potentially National Code of Standards accreditation requirements.
Addressed to: Scape Living Student Accommodation
AI-generated concerns summaryCarers were unable to recognise aspiration pneumonia, and there was a lack of clarity regarding their training on this condition. The company witness could not confirm the trainers' qualifications or the contents of relevant policies.
Addressed to: MiHomecare
AI-generated concerns summaryThe coroner identified a risk of further deaths due to the impact of Imprisonment for Public Protection (IPP) sentences on prisoners who feel trapped and have limited hope for release.
Addressed to: HM Prison and Probation Services
AI-generated concerns summaryThe coroner raises concerns about the lack of validation rules in general practice IT systems, which allowed an incorrect BMI to be recorded. This data entry error led to an individual being wrongly classified as vulnerable, highlighting a need for improved data reliability.
Addressed to: BMA and RCGP; EMIS; NHS England; TPP; Vision and Cegedim
AI-generated concerns summaryThe coroner raises concerns about the limited and conflicting guidance available to dentists in England and Wales regarding antibiotic prophylaxis for patients at increased risk of infective endocarditis. The current NICE guideline lacks implementation advice, and alternative European guidelines followed by cardiologists conflict with it.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner identified the absence of a clear mechanism for coordinating multiple medical disciplines across different hospital sites under single leadership for complex patient care.
Addressed to: Greater Manchester Integrated Care; NHS England
AI-generated concerns summaryConcerns were raised regarding Epsom General Hospital's discharge planning policy, which remains under review, and a clinician's misunderstanding of capacity in relation to an unsafe discharge. Additionally, pressure to vacate hospital beds was noted to impact clinicians' ability to prepare properly considered discharge plans, leading to rushed decisions.
Addressed to: NHS England; St George’s Epsom and St Helier Group
AI-generated concerns summaryThe coroner raised concerns about the Rugby Football League's Welfare Policy, which allows non-Super League clubs to seek dispensations from rules regarding drug education. This creates an inconsistent approach for young players who would benefit from a defined Code of Conduct across all tiers of the sport.
Addressed to: Rugby Football League
AI-generated concerns summaryThe coroner noted that current Building Regulations do not require fixed window restrictors in high-rise residential buildings, nor is there a requirement to retro-fit them for existing window designs.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner identified insufficient staffing to provide adequate falls mitigation support on wards with a high proportion of at-risk patients, leading to patients not being appropriately safeguarded. This issue is exacerbated by medically stable patients remaining on wards due to a lack of community care, increasing their fall risk.
Addressed to: Department of Health and Social Care; NHS England