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 raised concerns that NICE and international guidance do not sufficiently caution clinicians about the risk of misidentifying abdominal aortic aneurysm and acute pancreatitis due to their similar presenting features. The guidance does not specifically require the exclusion of an aneurysm when a pancreatitis diagnosis is uncertain.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that West Midlands Ambulance Service consistently failed to meet emergency response targets because significant hospital handover delays compromised ambulance crew availability, which created a risk to life.
Addressed to: Birmingham Integrated Care Board; Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified inadequate and infrequent training for care home staff on emergency response, including choking, which resulted in suboptimal resuscitation and the incorrect use of emergency numbers.
Addressed to: Meadow House
AI-generated concerns summaryThe coroner expressed concern about the free availability and marketing on Amazon.co.uk of books providing clear instructions on how an individual might end their life, noting the lack of regulation for such publications.
Addressed to: Amazon UK; Department for Business and Trade; Department for Culture, Media and Sport
AI-generated concerns summaryThe coroner identified issues with the grading of the police response, significant delays in attendance, and incident oversight due to resource limitations. The report also questioned the comprehensive demonstration of improvements in police response timeliness and incident management across the force area.
Addressed to: Northumbria Police
AI-generated concerns summaryThe coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.
Addressed to: HMP Stoke Health; Local Authority for Stoke on Trent
AI-generated concerns summaryConcerns include inconsistent falls prevention care plans and risk assessments, staff being unclear on mitigation, and insufficient supervision for high-risk residents in communal areas and bedrooms. The coroner also noted potential inadequacy of staffing levels.
Addressed to: Limes Care Home
AI-generated concerns summaryThe coroner notes a lack of clear understanding and accountability between agencies when young people transition from CAMHS to adult services, compounded by a lack of national guidance and recognised pathways for support.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the DVLA's medical assessment process for Category D licence holders, specifically the lack of a mechanism to diagnose asymptomatic individuals at risk of cardiac events. The report suggests implementing a risk-based stratification system or periodic stress tests, and adding HbA1c and cholesterol results to the …
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted a significant delay in antibiotic administration and questioned the accuracy of medical records regarding canula siting. Concerns were also raised about the effective administration of prescribed medication and existing checks to ensure this.
Addressed to: Northumbria Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the inappropriate categorization of emergency calls indicating an overdose, the absence of clinician involvement during these calls, and the lack of escalation when the individual became unresponsive to follow-up attempts.
Addressed to: Department of Health and Social Care; North West Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted staff misunderstandings regarding the level two observation policy and concerns about agency staff training. There was also a lack of routine supply of ligature cutters to observation staff in a ward where self-harm was not uncommon.
Addressed to: Somerset Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of overarching guidance for health and social care practitioners on applying legal frameworks to manage and protect individuals with chronic alcohol dependence, particularly concerning complex mental capacity assessments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryCoroners are concerned that General Practitioners may not be sufficiently aware of the fatal overdose risks associated with Propranolol, noting that this lack of awareness could contribute to future deaths if quantities are prescribed to at-risk patients.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a failure to recognise a patient's prolonged choice not to eat or drink as an action to end their life, thereby elevating suicide risk. The Trust's subsequent response did not sufficiently address this finding.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding insufficient trained paediatric nurses, a general lack of recognition of the child's severe illness by Emergency Department staff, and ineffective medical handovers with inadequate documentation of key information and clinical plans.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the emergency department being overwhelmed and understaffed, impacting patient safety. Staff did not adequately consider a diagnosis of sepsis, nor did they fully understand the implications of unrecordable blood pressure and the importance of continuous observations for seriously unwell patients.
Addressed to: Department of Health and Social Care; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryInsufficient paediatric nursing staff in the Emergency Department does not meet RCPCH standards, especially during high-pressure periods. The coroner also noted a lack of routine handover documentation and an unrobust system for recognising ill babies in ED.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner questioned Norfolk and Suffolk NHS Foundation Trust's decisions on patient discharge following failed engagement and their urgent referral responses, including risk assessment and downgrading. The report also notes insufficient implementation of safety measures and failure to preserve call recordings.
Addressed to: NHS England; Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryConcerns included insufficient information sharing across Children and Adult Services, a lack of documented rationale for decisions on care needs and safeguarding, and inadequate health-related enquiries despite indicators of mental impairment.
Addressed to: Chief Probation Officer; Cornwall Council; Devon & Cornwall Police