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 a lack of entitled domiciliary care for Regina Ademiluyi, caused by an insufficiently detailed safeguarding report that did not prompt further investigation by the local authority. Concerns were also raised about the absence of a formal mental capacity assessment and the lack of meaningful reflection by the …
Addressed to: East London Foundation NHS Trust; Newham Social Care
AI-generated concerns summaryConcerns included limited communication and unclear discharge information between health services and the prison regarding Mr Davies' condition. The prison lacked clear care plans, a food/fluid refusal policy, and sufficient staffing, while frontline staff lacked clear patient information.
Addressed to: Cardiff and Vale University Health Board; HMP Cardiff; Ministry for Justice; Swansea Bay University Health Board
AI-generated concerns summaryThe coroner expresses concern about the ready availability and expedited delivery of a "well known suicide book" on Amazon.co.uk. The report notes Amazon's continued sale despite displaying warnings regarding the book's potential to increase the effectiveness of suicide attempts.
Addressed to: Amazon UK
AI-generated concerns summaryThe coroner noted a significant delay in ambulance response, with a Category 2 call receiving an ambulance 1 hour and 56 minutes after the call, partly due to offloading delays at hospitals tying up ambulance resources.
Addressed to: Department of Health and Social Care; West Yorkshire Integrated Care Board
AI-generated concerns summaryThe coroner noted the absence of a legal requirement for seatbelts in the rear of motorhomes, allowing passengers, including children over three, to travel unrestrained, which could pose a risk to life.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted no legal obligation for seat belts in the rear areas of motorhomes, allowing unrestrained travel for adults and children over three, which may create a risk to life.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted a vacant Consultant Psychiatrist post in the community mental health team since May 2022 and an ongoing shortage of inpatient psychiatric beds in Surrey, both due to national shortages, presenting a risk of future deaths.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raises concerns about ongoing infrastructure risks at East Surrey Hospital that could delay hip fracture operations. The hospital's use of a 48-hour surgery metric, rather than the NICE guideline timeframe, may place patients at risk of complications and early death.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted a lack of investigation into multiple inpatient falls, particularly one that contributed to the patient's death. This meant the court was not reassured about preventing similar future deaths.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted staff lacked understanding of neonatal deterioration signs and infection risks, along with persisting cultural and communication issues between maternity and neonatal staff. Concerns were also raised about the absence of effective systems for tracking reviews and assessing capacity for planned inductions.
Addressed to: University Hospitals of Derby and Burton NHS Foundation Trust
AI-generated concerns summaryThe coroner noted no policy existed between Stockport Metropolitan Borough Council and Stockport Homes for managing equipment installation requests. This meant there was no review process to confirm urgent equipment installation, repair completion, or to identify delays.
Addressed to: Stockport Homes; Stockport Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted gaps in the provision of suitably trained and supervised carers, along with significant errors in the care and support plan and insufficient monitoring of the care agency.
Addressed to: Care Quality Commission; Home Dot Care Limited; Islington Social Services
AI-generated concerns summaryThe coroner noted that despite a warning 'flag' for an individualised care plan, it was hard to locate in the patient's records and was not considered during his admission. This creates a risk of further deaths.
Addressed to: Royal Hallamshire Hospital
AI-generated concerns summaryThe coroner identified that the private psychotherapist kept no clinical records, provided no evidence of ongoing assessment or risk assessment, and lacked clear therapeutic boundaries. Communication was also insufficient between the private and NHS mental health services.
Addressed to: Brainwaves; Care Quality Commission; Council of Psychotherapy; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted that staff repeatedly attributed continued respiratory effort to "a release of air" rather than a clinical change requiring further assessment, and there was no evidence of training against this explanation.
Addressed to: South Western Ambulance Service Trust
AI-generated concerns summaryThe coroner identified inadequate record keeping, healthcare staff failures in observation and assessment, and a lack of care plans and communication protocols between healthcare and prison staff. There was insufficient understanding among prison staff of emergency procedures, leading to delays in hospital transfer.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted inadequate supervision of a vulnerable person by a support worker unfamiliar with policies, and expressed concerns about insufficient monitoring and policing of homeless encampments where multiple deaths have occurred.
Addressed to: Care Quality Commission; London Borough of Waltham Forest; Metropolitan Police Service; Outlook Care Ltd
AI-generated concerns summaryThe coroner identified delays in medical and consultant reviews for leg bruising and haematoma. Concerns also included the consideration of discharge despite a surgical referral recommendation for an infected haematoma, delayed antibiotic commencement, and the sepsis protocol not being followed.
Addressed to: Princess Alexandra NHS Trust
AI-generated concerns summaryThe coroner noted long waiting lists for mental health support and insufficient resources for stable housing for vulnerable homeless young people, particularly LGBTQIA individuals who are at risk of exploitation. Concerns were also raised about the lack of overall ownership and coordination among multiple agencies involved in supporting these individuals.
Addressed to: Department for Local Government; Department of Health and Social Care; Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner noted that differing call categorisation and downgrading pathways among ambulance services lead to inconsistent approaches across England, potentially impacting the dispatch of ambulances for life-saving attendance.
Addressed to: Department of Health and Social Care