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 a disconnection between hospital and community psychology services, with insufficient handover and long waiting times for community sessions. Concerns were also raised about clinicians potentially being unable to access patient notes across different computer systems.
Addressed to: Essex Partnership University Trust
AI-generated concerns summaryThe coroner notes the thrombectomy service for stroke patients operates only during limited weekday hours, denying access to this time-sensitive treatment for those suffering a stroke outside these times. This creates a disparity in access based on when a stroke occurs.
Addressed to: NHS England; Stroke, East Kent Hospitals University NHS Foundation Trust; West Yorkshire and Harrogate Integrated Stroke Delivery Network; West Yorkshire Integrated Care Board; Wirral University Teaching Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding the under-reporting of adverse reactions to hair dye to manufacturers, noting a significant disconnect between industry statistics and independent research on the true incidence of allergic reactions.
Addressed to: CPTA
AI-generated concerns summaryThe coroner identifies insufficient connectivity between mental and physical health services, particularly for neurodivergent patients, and notes a lack of a comorbidity policy. Further concerns include the pace of developing a personality disorder pathway and ineffective communication with families of mental health patients.
Addressed to: Hampshire and Isle of Wight Integrated Care Board; NHS England; Southern Health Foundation Trust
AI-generated concerns summaryThe coroner noted a significant delay in ambulance response time for a Category 2 call, attributed to the ambulance service not being adequately resourced for call volume and delays in offloading patients at hospitals.
Addressed to: Department of Health and Social Care; South Yorkshire Integrated Care Board
AI-generated concerns summaryThe coroner noted concerns that dementia patients at the Trust may not be receiving mouth care on each occasion they eat, which presents a risk of future deaths.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner raises concerns about the potential dangers to patients associated with the prolonged prescription and use of opiate medication.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe coroner identified gaps in the knowledge, training, and guidance for clinicians supporting transgender individuals in mental health and primary care. Concerns also include delays in accessing gender-affirming healthcare and a lack of mental health provision for those awaiting treatment.
Addressed to: Gender Identity Clinic; NHS England; Surrey and Borders NHS Partnership Trust; Royal College of General Practitioners
AI-generated concerns summaryThe coroner identified gaps in tracking and following up A&E patients with outstanding test results after discharge, noting reliance on un-auditable oral handovers and incomplete implementation of abnormal result reviews.
Addressed to: Chelsea and Westminster Hospital; NHS England
AI-generated concerns summaryThe coroner noted the unacceptable level of care expected from Catriona’s mother and a lack of guidelines for delegating nursing duties or for the nursing team's supervision and intervention requirements.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryInsufficient medical practitioner cover over a bank holiday period meant no doctor assessed the patient's routine care needs, potentially being as detrimental as a lack of emergency cover.
Addressed to: NHS England; University Hospitals of Leicester NHS Trust
AI-generated concerns summaryNational prison and healthcare record systems lack a mechanism to highlight significant dates for prisoners, impacting the provision of timely support. Staffing pressures and limitations within the NOMIS system also hinder prison staff from fully reviewing records, leading to crucial information being overlooked.
Addressed to: HM Prison and Probation Service; NHS England; Ministry of Justice
AI-generated concerns summaryThe coroner identified concerns regarding a culture that may prevent medical staff from taking account of views from parents or nursing staff, and questioned the adequacy of learning explanations for junior doctors when overruled.
Addressed to: Sheffield Children’s NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that CCTV coverage at the station did not extend beyond the concourse and that footage was not immediately available to Route Control, despite the risk of incidents at busy stations.
Addressed to: Department for Transport; Network Rail
AI-generated concerns summaryVulnerable adults under the care of secondary mental health services by East London NHS Foundation Trust receive very limited or no support despite being at risk of prescription drug overdose or mental health crisis.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that mould in properties owned and maintained by Mansfield District Council, including Mrs. Bennett's, may pose a risk of future deaths. The report asks for inspections and action to minimise tenant exposure.
Addressed to: Mansfield District Council
AI-generated concerns summaryThe coroner identified insufficient specialist consultant review for a patient with a high NEWS score, and noted concerns regarding unquantified risks and inadequate informed consent for the ascitic tap procedure.
Addressed to: Mid Yorkshire Hospitals NHS Trust; Royal College of Radiologists
AI-generated concerns summaryThe coroner identified a lack of understanding between Acute and Mental Health Trust clinicians regarding the specific role of the Mental Health Liaison Team for eating disorder patients. There was also a lack of clarity on referral pathways to specialist eating disorder services.
Addressed to: Northern Care Alliance; Pennine Care NHS Trust
AI-generated concerns summaryThe coroner identified a lack of a specialist service for GPs to refer patients with difficult venous access for blood tests, which in this case meant a diabetes test could not be obtained.
Addressed to: Greater Manchester Integrated Care Partnership Board
AI-generated concerns summaryThe coroner identified national shortages of specialist scanning facilities and significant delays in the two-week cancer pathway, leading to delayed diagnoses and treatments, which impacts patient outcomes.
Addressed to: NHS England