Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified that established surgical referral pathways were not followed and an urgent CT scan was omitted. Concerns also noted inadequate recognition of patient deterioration, particularly for those with communication difficulties, and insufficient consideration of input from family.
Addressed to: Sandwell and West Birmingham NHS Trust
AI-generated concerns summaryCoroner noted difficulties for medical staff in contacting the hospital switchboard and a cardiology team's unawareness of an emergency GP phone number. The patient's case was not discussed at a Multi-Disciplinary Team meeting due to an uncompleted referral.
Addressed to: Department of Health and Social Care; NHS England; South Warwickshire University NHS Foundation Trust; University Hospitals Coventry and Warwickshire NHS Trust
AI-generated concerns summaryThe coroner raised concerns that Oxleas NHS Trust staff relied on an incomplete summary from a British Transport Police referral, failing to scrutinise the full report or make further inquiries. This led to an inadequate risk assessment and a missed opportunity to implement a more robust care plan.
Addressed to: Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of local and national in-cell ligature point risk assessments and maps, meaning staff were unaware of their locations. There is also no mandatory requirement for HMP Prisons to have designated safer cells, which HMP Nottingham lacked.
Addressed to: HM Prison and Probation Services
AI-generated concerns summaryThe external staircase where Mr Hedges fell had worn steps without a non-slip surface or highlighting, an inadequately short handrail, and poor lighting, raising concerns about user safety.
Addressed to: Gravesham Borough Council
AI-generated concerns summaryThe coroner noted that independent doctors conducting Mental Health Act Assessments may not have full access to patient records due to non-mandated training. There was also a lack of understanding regarding voluntary admission and the least restrictive option.
Addressed to: Devon Partnership NHS Trust
AI-generated concerns summaryUnregulated websites are selling prescription-only medications without requiring prescriptions, enabling repeat orders, and potentially exploiting vulnerable individuals with addictions. There is also concern these sites could provide means for self-harm.
Addressed to: Department for Culture, Media and Sport
AI-generated concerns summaryThe coroner identified concerns regarding inadequate "No Entry" signage at the A5 slip road at Little Brickhill, exacerbated by the wide exit, poor lighting, and frequent wrong-way entries by drivers. This creates a risk of high-speed collisions.
Addressed to: Apple; Google; Milton Keynes City Council; National Highways; TomTom
AI-generated concerns summaryThe coroner raised concerns about a nationwide shortage of care providers and carers, which meant a commissioned care package could not be provided. This lack of care risks individuals not receiving necessary support, potentially leading to fatal outcomes.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified limited information sharing and hasty arrangements for patient transfers between care facilities, including a lack of updated care assessments. Concerns were also raised about one facility's inability to refuse referrals despite insufficient information.
Addressed to: Nottinghamshire County Council
AI-generated concerns summaryConcerns include an incomplete Trust investigation that missed key issues, unresolved policies regarding prohibited items like belts on the ward, and failures in escalating patient risk and responding to bathroom alerts.
Addressed to: Essex County Council; Essex Partnership University Trust
AI-generated concerns summaryThe coroner noted delays in triaging Mr Campion's call, which resulted in an overdose, and further ambulance dispatch delays due to high service demand, impacting his receipt of timely medical and psychiatric assistance.
Addressed to: Department of Health and Social Care; NHS England; NHS Improvement
AI-generated concerns summaryThe coroner noted the ambulance response time of 3 hours and 18 minutes likely affected the outcome. This was exacerbated by insufficient Emergency Medical Dispatchers, staffing levels below demand, and significant delays in offloading patients at hospitals.
Addressed to: Department of Health and Social Care; West Yorkshire Integrated Care System
AI-generated concerns summaryThe cost of histological analysis in private treatment may deter patients from crucial diagnostic tests routinely included in NHS care. This disparity poses a risk of future deaths by hindering early cancer detection.
Addressed to: Cambridgeshire Peterborough Integrated Care System; Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified an apparent lack of systems for recording and tracking highway hazard reports, meaning there was no information on whether inspections occurred or if recommended work was completed. This absence of clear data on maintenance status creates risks across the county.
Addressed to: Cambridgeshire County Council
AI-generated concerns summaryThematic clinical notes hindered the sharing of critical information, and structured risk management tools were not utilised. A multi-agency plan to alert care coordinators to railway station attendances was also ineffective, particularly for unstaffed stations.
Addressed to: British Transport Police; Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an online forum that encourages suicide, shares methods, and lacks age restrictions, content moderation, and prevention signposting. Further concerns related to the unregulated online availability and delivery of a specific product to the UK.
Addressed to: Amazon; Border Force; British Transport Police; Department for Culture, Media and Sport; Department of Health and Social Care; Google; Home Office; Ofcom; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted that a thematic review of mental health services identified significant issues, but actions were not effectively implemented. Additionally, Serious Incident Investigations continue to be significantly delayed, compromising evidence and patient safety improvements.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner noted dangerous junior orthopaedic staffing levels led to missed patient reviews, and consultants lacked access to NEWS charts during ward rounds. There was also confusion among doctors regarding responsibility for the patient's care.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of out-of-hours emergency endoscopy, insufficient staff and space in the Emergency Department, and ineffective triage of ambulance patients. Concerns also included a lack of clear understanding of critical pathways and issues with sharing learning from investigation reports.
Addressed to: Betsi Cadwaladr University Health Board; Department of Health and Social Care