Browse 6,458 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 raised concerns that the "latching" facility on patient monitoring equipment in Emergency Departments can contribute to alarm fatigue, masking new alarms and potentially affecting staff response, with its continued use elsewhere unknown.
Addressed to: NHS Wales; NHS England; Worcestershire Acute Hospital NHS Trust
AI-generated concerns summaryThe coroner identified that the NHS website's description of necrotising fasciitis is unclear, potentially hindering diagnosis by not clarifying that the condition can present as intense pain without a noticeable wound or skin changes.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified risks of medication prescription and administration errors and insufficient liaison between hospital and prison healthcare for patient discharge. Concerns included the lack of a formal policy for healthcare staff to access cells at night for monitoring.
Addressed to: Chief Executive Officer, Practice Plus Group, 3rd Floor, 5 Lloyd’s Avenue, London EC3N 3AE 2. Chief Executive Lewisham and Greenwich NHS Trust, University Hospital Lewisham, Lewisham High Street, London SE13 76LH 3. The Director at HMP Thameside, Griffin Manor Way, London, SW28 0FJ. 4. Director General/Chief Executive HM Prison and Probation Service (HMPPS), 102 Petty France, London, SW1H 9AJ. 1CORONER I am Jenny Goldring assistant coroner, for the coroner area of Inner London South 2CORONER’S L; Serco
AI-generated concerns summarySuicide prevention training is not mandatory for frontline staff in Warwickshire Children’s Services, leading to variability in practice. This meant staff did not directly explore suicidal ideation or signpost to crisis support for Matilda.
Addressed to: Warwickshire County Council – Children and Young People; Warwickshire County Council – Children with Disabilities team
AI-generated concerns summaryThe coroner identified inadequate record-keeping with significant gaps in evidence of care provision, particularly for medication and catheter management. Concerns were also raised regarding the absence of formal, assured training arrangements for staff delivering commissioned care.
Addressed to: Multi-Care Community Services Suffolk
AI-generated concerns summaryThe coroner raised concerns regarding the up to 14-day triage period for non-urgent mental health referrals to the Single Point of Access (SPA), especially when referrals could be made by individuals without mental health experience.
Addressed to: South West Yorkshire Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding limited awareness and identification of salbutamol overuse, significant ambulance handover delays impacting emergency availability, and unclear wording in NHS Pathways triage questions.
Addressed to: Asthma & Lung (for information); Care Quality Commission; NHS England; NHS Pathways/NHS Digital (NHS England Transformation; Royal College of GP’s; Department of Health and Social Care
AI-generated concerns summaryConcerns at HMP Pentonville include improper management and implementation of the ACCT process, inadequate record-keeping, insufficient accountability, and training gaps. Additionally, a nurse performed futile and undignified CPR during a medical emergency.
Addressed to: HM Prison Pentonville; Practice Plus Group
AI-generated concerns summaryThe coroner noted borrowed equipment lacked clear instructions, with small on-device warnings for enclosed spaces. Training on carbon monoxide risks had not reached individual troop trainers, and observed practices by adult leaders may have influenced the deceased.
Addressed to: Scouting Association
AI-generated concerns summaryThe coroner identified issues with communication and accurate record-keeping of heat sources and search outcomes, which led to uncoordinated searches and delays in deploying specialist units. Additionally, an officer lacked essential operational PPE and equipment during a night search.
Addressed to: Cleveland Police
AI-generated concerns summaryThe coroner identified a lack of follow-up from the GP practice for Melanie despite her expressing suicidal ideation, and a prescribed medication request was not actioned by a GP.
Addressed to: Unity Healthcare
AI-generated concerns summaryThe coroner noted the store's access ramp is unsafe, being unfixed to the ground, having a movable rubber mat, lacking handrails, and being too short, which creates a high risk of falls for customers.
Addressed to: Sai SKN Ltd
AI-generated concerns summaryA senior doctor disregarded junior clinicians' concerns about a child's symptoms. The external radiology service lacked paediatric expertise, resulting in a missed diagnosis, and staffing limitations caused delays in critical scans and intubation.
Addressed to: Mid Yorkshire Teaching Hospital NHS Trust; Telemedicine Clinic Limited
AI-generated concerns summaryThe report identifies a lack of practical guidance for police officers when making communications data applications under the Investigatory Powers Act 2016. This includes insufficient clarity on what constitutes an urgent Grade 2 request and appropriate application methods.
Addressed to: National Police Chiefs' Council; College of Policing; Devon and Cornwall Police; Dorset Healthcare NHS Trust; Dorset Police
AI-generated concerns summaryThe coroner raised concerns that nationals from non-designated countries can continue to drive on foreign licences for 12 months, even after failing a GB driving test, without supervision or 'L' plates. This differs from the rules for GB residents and poses a potential risk to other road users.
Addressed to: Department for Transport; Driver and Vehicle Standards Agency
AI-generated concerns summaryThe coroner identified a low coefficient of friction on the road surface at the bend where the collision occurred. Additionally, there was an absence of advance warning signage to alert drivers to the severity of the notorious bend.
Addressed to: Northumberland County Council
AI-generated concerns summaryThe coroner identifies that in-cell automatic fire detection (AFD) has not yet been implemented at Eastwood Park prison and other prisons, and that current domestic smoke detectors are a less effective mitigation. There is also a noted delay in implementing AFD across the prison estate.
Addressed to: Director General Operations; Ministry of Justice
AI-generated concerns summaryThe coroner identified a lack of statutory regulation for sleep support services and the misleading use of 'maternity nurse' titles by unqualified individuals. This facilitates the promotion of unsafe practices like prone sleeping, which increases the risk of sudden unexpected death in infants.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified confusion regarding the interpretation of 'urgent' in cardiology referrals among third-party providers and noted differing understandings between GPs and hospital consultants on expediting referrals. This includes a need for clearer guidance for GPs on appropriate pathways for complex cases.
Addressed to: NHS North Central London Integrated Care Board
AI-generated concerns summaryThe coroner noted a lack of regular refresher training in mental health first aid for frontline police officers, which is not provided on a recurring basis as physical first aid training is.
Addressed to: Greater Manchester Police