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 noted concerns in adult social care, including insufficient regard for practitioner safeguarding observations at triage. Issues also arose from cases closed despite recommendations and procedural gaps in referral and allocation processes.
Addressed to: Westmorland and Furness Council
AI-generated concerns summaryGaps in communication between specialist teams on urgent referral pathways delayed result sharing and overlooked investigation reporting times. The coroner also noted that endoscopist training, focused on specialty, may limit the recognition of less common lesions.
Addressed to: Department of Health and Social Care; Royal College of Physicians; University Hospitals Bristol and Weston NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a national policy for the placement of Central Venous Catheters (CVCs). Doctors giving evidence highlighted the lack of a single standard national policy and suggested one would be beneficial.
Addressed to: Association of Anaesthetists; Department of Health and Social Care; National Infusion and Vascular Access Society; National Institute for Health and Care Excellence; Royal College of Anaesthetists
AI-generated concerns summaryThe coroner noted the need for robust protocols to manage patients who deteriorate during a key staff member's leave, especially when not initially requiring handover, and when both key points of contact are simultaneously absent.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that a new drug detoxification discharge pathway for prisoners at HMP Chelmsford lacks formal documentation, including protocols and policies. This absence prevents consistent implementation and monitoring, raising concerns about future risks to prisoners.
Addressed to: Castle Rock Group; Forward Trust
AI-generated concerns summaryThe coroner's concerns included a vulnerable adult being "lost in the system" with inadequate follow-up and inappropriate housing. There was also a lack of long-term support for cyclical mental ill health, delays in accessing services, insufficient family engagement, and ongoing staffing shortages.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified inadequate welfare checks, insufficient meaningful engagement, and a failure to re-contact the crisis team regarding a vulnerable resident's worsening condition. Gaps included staff's lack of self-harm awareness training and the hostel not holding family contact details.
Addressed to: Depaul UK
AI-generated concerns summaryThe coroner noted East Surrey Hospital is not meeting NICE guidelines for hip fracture surgery, with over half of patients experiencing delays beyond the recommended timeframe. This non-compliance was identified as potentially placing patients at risk of early death.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner raised concerns that Naloxone was not administered to Ms Newbury despite paramedics being informed of illicit drug use and her history of opiate misuse. This issue has arisen in previous inquests where other reversible causes were treated.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted that street lighting along Trinity Road was unilluminated at the time of a road traffic collision due to an underground cabling fault. This damage may have stemmed from a previous road traffic collision.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner identified gaps in recording previous self-harm methods and obtaining family information during initial referrals and admissions. Difficulties in private sector providers accessing NHS notes also created significant information gaps, impacting risk assessments and care plans.
Addressed to: Langford Centre; NHS England
AI-generated concerns summaryConcerns include restricted police access to the pier's lower level, inaccessible and insufficient life-saving rings, and a life-saving ring rope that was too short to reach the water at low tide.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner identified a lack of structured training for bridge staff in identifying and interacting with vulnerable individuals, including specific input from mental health professionals or negotiation skills. Concerns also covered delays in emergency service response for vulnerable persons.
Addressed to: Human Resources
AI-generated concerns summaryDelayed discharge of out-of-area mental health patients was noted due to underfunded local beds and reliance on independent providers. Communication gaps stemmed from varied processes, incompatible IT systems, and no national repatriation standards.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryPlanned changes to paediatric specialist training will reduce experience in Level 3 Neonatal units. This may lead to less practical experience for middle grades in neonatal resuscitation and a lower level of experience for future consultant general paediatricians.
Addressed to: Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner raised concerns about the limited sharing of electronic mental health records between NHS trusts, hindering timely access to patient history. Within the mental health unit, issues included the recording and storage of handover information and the reliance on paper records.
Addressed to: NHS England; Portsmouth Hospitals University NHS Trust; Solent NHS Trust
AI-generated concerns summaryThe coroner identified continuing and regular instances of ambulance non-availability in Suffolk and the East of England, resulting in attendance times falling short of targets due to insufficient resources.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in how carers' health and safety concerns were addressed and recorded, lacking clear staff guidance. There were also concerns that Owen's supervision deviated from his risk assessment without clear guidelines for teachers.
Addressed to: Health and Safety Executive; Unity MAT
AI-generated concerns summaryThe coroner identified concerns regarding the mental health referral system, where an urgent GP referral for secondary psychiatric assessment was diverted to the primary mental health team without the referring GP's knowledge. This lack of clarity meant GPs were unaware their referrals for specialist input might not reach the intended …
Addressed to: Birmingham and Solihull Integrated Care System; Birmingham and Solihull Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a ten-hour ambulance response delay for an elderly individual after a fall, significantly missing the allocated target time. This prolonged 'long lie' risks terminal kidney injury and death for frail, elderly individuals, necessitating a review of emergency call management.
Addressed to: Association of Ambulance Chief Executives; East of England Ambulance Service NHS Trust; NHS England; Royal College of Emergency Medicine