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 incomplete suicide risk assessments and insufficient exploration of suicidal thoughts, medication, coping strategies, and support networks during mental health contacts. Concerns were raised regarding a lack of assurance for system changes to ensure proper risk assessment completion.
Addressed to: Midlands Partnership Foundation Trust
AI-generated concerns summaryMissed opportunities to gather collateral history due to inaccessible information systems and untimely handling of a risk assessment form were identified. There were also issues regarding the adequacy and clarity of care plan documentation.
Addressed to: NHS England; Surrey and Borders Partnership NHS Foundation Trust; Surrey County Council; Surrey Police
AI-generated concerns summaryThe coroner noted the absence of a physical barrier at the bottom of the weir, identifying it as hazardous due to recirculating flow, particularly during high water levels.
Addressed to: Department for Environment, Food and Rural Affairs; Environment Agency
AI-generated concerns summaryOut-of-date medical training for bank staff, inadequate risk assessment updates post-medical events, and problems with emergency response procedures were identified. These included a lack of portable phones, unclear paramedic guidance, and a non-functional AED clock.
Addressed to: Gloucestershire Health and Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of contact details for psychiatric liaison nurse services and CMHT/crisis teams in neighbouring boroughs, hindering direct referral and information sharing for individuals seeking urgent mental health support.
Addressed to: NHS England
AI-generated concerns summaryHighway operatives lack specific training to identify road defects hazardous to cyclists, and no policy review has occurred since a death. Concerns also exist regarding Island Lane's road surface and underlying geological features, which require adequate identification of hazardous defects during inspections.
Addressed to: Lancashire County Council
AI-generated concerns summaryThe coroner identified significant delays in ambulance response to a man with a head injury. Concerns included a failure to upgrade call status despite reported deterioration, and that initial calls were not adequately actioned.
Addressed to: South East Coast Ambulance Service
AI-generated concerns summaryThe coroner noted insufficient academic advisor support for students facing academic pressures and questioned the use of penalties for late work. Additionally, flawed communication between university departments meant a critical link between health services and student support was missing.
Addressed to: University of Sussex
AI-generated concerns summaryThe coroner noted that a consultant surgeon could not access electronic records from other hospital departments during weekends and out-of-hours, highlighting the importance of full access for authorised personnel.
Addressed to: Brighton and Sussex University NHS Hospital Trust
AI-generated concerns summaryThe coroner noted a lack of recording the patient's reported physical health issues during admission to a psychiatric hospital, and insufficient efforts to ascertain a full past physical history. This highlights gaps in information sharing and accessing patient medical history between trusts.
Addressed to: NHS England; Department of Health; Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified ongoing non-compliance with Control of Substances Hazardous to Health Regulations (COSHH), alongside inadequate training and monitoring for staff handling hazardous substances. Concerns were also raised about confusion in staff roles, failures in communicating important practices, and a lack of systems for reporting and learning from suboptimal events.
Addressed to: Brighton and Sussex University NHS Hospital Trust
AI-generated concerns summaryThe coroner noted a lack of institutional learning regarding ambulance calls for reported deaths and found officer training on responding to hanging casualties, especially for those receiving online-only training, to be inadequate. Concerns were also raised about officers not receiving timely First Aid refresher training, including specific resuscitation techniques.
Addressed to: Greater Manchester Police; College of Policing
AI-generated concerns summaryConcerns were raised regarding the Ministry of Justice's discharge of a high-risk patient without adequate Mental Health Tribunal scrutiny, the absence of forensic pathways for s.41 restricted patients in the locality, and gaps in police powers to arrest individuals posing a serious risk in relationships.
Addressed to: Cygnet Health Care; Derby City Council; Derbyshire Constabulary; Derbyshire NHS Foundation Trust; Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns about CNWL's duty of candour and staff operating outside policy, alongside insufficient training for SPA call handlers. Shortages in psychiatric care provision were also noted.
Addressed to: Central and North West London NHS Foundation Trust; Metropolitan Police Service; NHS England
AI-generated concerns summaryAdministrative errors causing distress through post-death letters revealed insufficient collaborative working on death notification between trusts. Both trusts also had outstanding Root Cause Analysis recommendations with delayed completion dates.
Addressed to: Black Country Healthcare NHS Foundation Trust; Dudley Integrated Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted a lack of specific guidance in academic literature, BNF, NICE, or MHRA regarding the risk of death from the combined effects of clozapine and alcohol. Existing medication leaflets advise against alcohol but do not explicitly state death as a possibility in this scenario.
Addressed to: BNF Publications; Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe coroner identified insufficient understanding of Avoidant Restrictive Food Intake Disorder (ARFID) and its medical emergencies among health, education, and social care professionals. Concerns include gaps in identification and management strategies, and limited specialist support for children, particularly those with autism.
Addressed to: Department for Education; Department of Health and Social Care; Greater Manchester Integrated Care; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted that vitamin supplements can pose serious risks when taken in excess, and current food labelling requirements do not mandate warnings or guidance about appropriate dosage and potential side effects on packaging.
Addressed to: Department of Health and Social Care; Food Standards Agency; NaturPlus UK
AI-generated concerns summaryConcerns included delays in night-time blood tests and CT scans, a lack of specific internal escalation policy for night-time, and insufficient training for clinicians on atypical sepsis presentation and the proper response to 'just to let you know' calls for Intensive Care Unit review.
Addressed to: Berkshire and Surrey Pathology Services; Royal Berkshire Hospital
AI-generated concerns summaryThe coroner noted a lack of compliance with medication review targets in GP practices and no standard practice for reviews, leading to variation between clinicians. This raised concerns about the risk of inadvertent overdose when central nervous system depressants are co-prescribed without regular review or specific patient advice.
Addressed to: Betsi Cadwaladr University Health Board