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 DWP did not use available support tools to record Naz's vulnerability or act on requests to direct communication through her daughter. The coroner also noted a lack of clear plans for training DWP staff to prevent similar issues.
Addressed to: Department for Work and Pensions
AI-generated concerns summaryThe coroner noted police officers did not voice their view of Acute Behavioural Disturbance (ABD) during an incident, despite later recording it as an impact factor. This raises concerns about the 'Speak Up and Speak Out' principle for junior officers.
Addressed to: Gwent Police
AI-generated concerns summaryStaff in the care home were not adequately informed about the importance of applying 'cooling by running water' for burns, with this not being proactively flagged in relevant policies or operational communications.
Addressed to: Care Quality Commission; Colton Lodges Nursing Home; HC-One Healthcare Company
AI-generated concerns summaryLack of clear instructions from the neurology department to GPs regarding medication changes, combined with a GP surgery workflow that prevented clinicians from reviewing crucial correspondence. This resulted in difficulties for the care provider in administering the correct medication dosage.
Addressed to: Brook Medical Centre; Godfrey Care; University Hospitals of North Midlands NHS Trust
AI-generated concerns summaryInadequate staffing, leadership, and patient escalation pathways were identified on wards opened for winter pressures. The electronic patient system also fails to record the author of discharge letter changes, risking miscommunication and treatment delays.
Addressed to: Care Quality Commission; CSC; Hull University Teaching Hospitals NHS Trust; NHS England
AI-generated concerns summaryConcerns were raised regarding a road section identified as an accident black spot, Dorset Council's lack of investigation into sources of water flowing onto roads, and Wessex Water's apparent absence of a robust system for logging and acting on direct reports of highway leaks.
Addressed to: Dorset Council; Wessex Water Services Limited
AI-generated concerns summaryThe new Cerner computer system in the Emergency Department lacks a "RAG rating" feature that previously allowed quick identification of patient acuity. The coroner notes this absence could hinder clinicians in rapidly identifying critically ill patients, particularly during high pressure.
Addressed to: County Durham and Darlington NHS Foundation Trust; Oracle Health UK
AI-generated concerns summaryThe coroner noted a lack of reliable liaison between Adult Social Care and care providers when capacity concerns are raised, leading to missed opportunities. There were also concerns that capacity assessments do not consistently account for variable and fluctuating capacity.
Addressed to: Cumberland Council Adult Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the absence of national guidance for investigating children suspected of swallowing non-radio opaque objects when symptoms persist after negative x-ray and fluoroscopy results, noting this matter would benefit from national consideration.
Addressed to: British Association of Paediatric Surgeons; Royal college of Paediatrics and Child Health; Royal College of Radiologists
AI-generated concerns summaryMental health practitioners did not remove an item observed in Mr Gill's home on May 3, 2023, despite his ongoing expression of suicidal ideation.
Addressed to: Coventry and Warwickshire NHS Partnership Trust; Department of Health and Social Care; Warwickshire Police
AI-generated concerns summaryThe coroner identified that there is no direct means for pharmacies to report to Recovery Steps when a service user stops collecting methadone, and no obligation to report wider welfare concerns. This situation may mean vulnerable service users do not receive additional support.
Addressed to: Recovery Steps Cumbria
AI-generated concerns summaryThe coroner raises concerns that handover delays at hospitals are impacting ambulance response times for patients needing emergency treatment, with delays significantly exceeding Welsh Health Circular targets.
Addressed to: Aneurin Bevan University Health Board; Department of Health and Social Care; Welsh Ambulance Service NHS Trust
AI-generated concerns summarySurrey County Council has not rigorously reviewed the death, with the coroner identifying ongoing gaps in care leaver support processes, adviser training, and risk assessment protocols. Concerns also relate to opaque processes for obtaining diagnoses and accessing adult social care.
Addressed to: Care Quality Commission; Surrey County Council
AI-generated concerns summaryThe coroner identified that national JRCALC guidance should consider incorporating the London Ambulance Service's JRCALC Plus recommendation for conveying patients with non-progressing deliveries to an obstetrics unit.
Addressed to: Association Ambulance Chief Executives; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that acutely psychotic prisoners requiring transfer to psychiatric hospitals under the Mental Health Act are left untreated, risking deterioration due to a shortage of suitable hospital bed spaces.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted inconsistent documentation for the deceased's high falls risk and a lack of review for the risk management plan after changes or falls. Training in falls risk was also outstanding for the majority of care home staff.
Addressed to: Stanley Park Care Centre
AI-generated concerns summaryThe ambulance service script advises callers not to call back for an estimated time of arrival, only for deterioration, which risks callers not recognising or reporting worsening conditions. This also limits opportunities for regular re-assessment during delayed responses.
Addressed to: Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.
Addressed to: Department of Health and Social Care; HCRG Care Services Ltd; Ministry of Justice
AI-generated concerns summaryThe coroner noted the absence of specific NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups. The report also highlighted that a NICE review of rapid antigen testing excluded children under five, where such testing could be beneficial.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner identified inadequate and difficult-to-access mental health support for service personnel with severe PTSD, both during their service and following discharge, which did not fully recognise the impact of traumatic events.
Addressed to: Ministry of Defence