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 summaryA significant delay in ambulance arrival and a subsequent extended wait of over 16 hours for hospital offloading contributed to the formation and exacerbation of a pressure sore.
Addressed to: Swansea Bay University Health Board; Welsh Ambulance Service
AI-generated concerns summaryThe coroner identified concerns about the GP's decision to increase methadone based on subjective symptoms, overlooking other evidence and signs of impaired consciousness. Also noted were pharmacy technicians' lack of training in consciousness assessment and record-keeping.
Addressed to: HMP Wandsworth; PPO; NHS England; Oxleas NHS Trust
AI-generated concerns summaryThe coroner noted a lack of comprehensive evidence that lessons had been learned regarding the District Nursing team's failure to provide appropriate offloading advice for pressure wounds and to escalate these issues. Further training and protocols to improve patient safety in this area were described as a work in progress.
Addressed to: County Durham and Darlington NHS Foundation Trust
AI-generated concerns summaryThe report notes insufficient supervision of call handlers in the Hampshire Police Control Room, with no clear plan for improvement. It also describes a lack of adequate structure for timely information sharing between NHS and private healthcare providers.
Addressed to: Hampshire and Isle of Wight Constabulary; NHS England
AI-generated concerns summaryInsufficient family involvement in patient risk assessment and safety planning was identified, alongside inadequate suicidal risk assessment and mitigation. The coroner also noted non-compliance with the Trust's planned leave policy and insufficient incident investigations.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryMiscommunication between a nurse and doctor delayed time-critical medication due to a bleep system that cannot convey electronic information. This system creates a risk of misunderstanding and impacts task prioritisation, potentially affecting patient safety.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identifies that some staff do not fully utilise ward-specific risk assessments and care plans. Also, the system for allocating and recording named nurses is inadequate, hindering investigations into their role.
Addressed to: Department of Health and Social Care; NHS England; Nottinghamshire Healthcare NHS Foundation Trust; OFCOM
AI-generated concerns summaryImportant steps in the husband's arrest and conditional pre-charge bail were not followed, including the failure to seek the alleged victim's views on bail conditions. Earlier police discussion might have identified the deceased's dependence and the need for alternative support.
Addressed to: Bedfordshire Police
AI-generated concerns summaryThe coroner noted a lack of local authority review into policies ensuring independent providers fulfil contractual duties for vulnerable individuals, and a lack of response from the Disclosure and Barring Service to a safeguarding referral.
Addressed to: Disclosure and Barring Service; Torbay and South Devon NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a system requiring radiographers to ensure pre-exposure markers are present in x-rays, and a lack of a system for radiologists to investigate inconsistencies in injury sites between images before finalising reports.
Addressed to: North Bristol Trust
AI-generated concerns summaryThe coroner identified chronic staff shortages and substantial backlogs within the neurology department, which impacted timely patient referrals and communication. Concerns were also raised regarding incorrect medication tapering regimes, insufficient time for accurate dosage assessment, and inadequate documentation of treatment plans.
Addressed to: Mid and South Essex NHS Trust; NHS England
AI-generated concerns summaryThe coroner identified a risk of missed diagnoses due to junior doctors not challenging consultant opinions, alongside inadequate urgent patient complaint systems and a lack of full investigation into the death.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted significant assumptions were made about Lee's whereabouts based on his addiction, which was not considered a vulnerability, and insufficient weight was given to information provided by his family about his state of mind and usual behaviours.
Addressed to: College of Policing
AI-generated concerns summaryThe coroner noted limited and retrospectively completed medical notes for Alissa following her birth, with some entries based on assumption rather than first-hand knowledge, hindering subsequent clinicians.
Addressed to: University Hospitals Sussex NHS Foundation
AI-generated concerns summaryThe coroner noted significant delays in ambulance response times, with an Amber 1 call waiting over six hours, due to ambulances being held up by hospital handover delays and an apparent shortage of funded resources.
Addressed to: Minister for Health and Social Services, Welsh Government
AI-generated concerns summaryThe coroner noted a lack of candour within The Scouts Association and the absence of independent regulatory oversight for its safety systems and activity permits. There was also concern about the failure to conduct a timely internal investigation report following the child's death.
Addressed to: Charity Commission for England and Wales; Children’s Commissioner for England; Children’s Commissioner for Wales; Department for Education; Health and Safety Executive; Minister for Education, Wales; Minister of State for Children and Families; Scouts Association; Unity Insurance Services: Scouting and Scout Groups Insurance
AI-generated concerns summaryThe coroner noted non-compliance with medication administration policies, with tablets left unsupervised for a patient with delirium. Additionally, the patient was repeatedly found unhygienic, requiring family members to assist with cleaning and changing.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the adequacy of arrangements for inpatient risk assessment and management, including anti-anxiety medication, and the implementation of intermittent observation at Farnham Road Hospital. Concerns also included information sharing between staff.
Addressed to: Surrey and Boarders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted ongoing gender-based bullying at JFS and a lack of confidence among some female students in the school's initiatives to address it.
Addressed to: Jewish Free School
AI-generated concerns summaryThe coroner identified concerns regarding the welfare of individuals subject to IPP sentences due to the ongoing uncertainty, fear of recall, and reluctance to seek mental health support for fear of impacting discharge.
Addressed to: Ministry of Justice