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 raised concerns regarding the adequacy, layout, traffic volume, movement complexity, and speed limits at a specific road junction and others on the A690. Planned improvements are deemed insufficient and untimely given future development, and do not consider the entire series of junctions.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner identified a lack of adequate training and shadowing for a new carer, which led to a service user requiring supervision being unattended and falling. Concerns were raised about the care agency's training and shadowing policies for new carers to prevent similar incidents.
Addressed to: Lean on Me Care Agency
AI-generated concerns summaryThe coroner noted a lack of follow-up on fire risks by building control and insufficient communication between planning and fire enforcement regarding building materials. Concerns were also raised about inadequate contractor documentation and a potential lack of public and contractor awareness of current fire safety duties and processes.
Addressed to: Health & Safety Executive; JHS Contracts; London Fire Brigade; Royal Borough of Greenwich
AI-generated concerns summaryThe coroner noted that numerous recommendations from previous inquiries regarding training for police staff involved in firearms licensing decisions had not been implemented. There has been a long-standing failure to develop and maintain nationally accredited training for firearms licensing staff, including in assessing applicant suitability.
Addressed to: Approved Clubs; self-governing schools; Chief Constables; College of Policing; Department for Education and Employment; Home Office; National Police Chiefs’ Council; independent schools
AI-generated concerns summaryThe coroner noted ambiguity in NICE Guidance for head injuries regarding CT scans for patients with naturally occurring conditions affecting blood clotting, similar to those on anticoagulant treatment, which may lead to missed opportunities for scanning.
Addressed to: The Chief Coroner for England and Wales; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted a lack of professional curiosity by medical staff in investigating severe pain and inadequately assessing a pressure ulcer, which contributed to a delayed diagnosis of Osteomyelitis. Concerns were also raised about the absence of mandatory training for clinical staff on pressure ulcers.
Addressed to: Barking, Havering & Redbridge NHS Trust
AI-generated concerns summaryThe coroner identified gaps in risk assessment and management plans during the patient's transition between mental health teams and when medication was weaned. Further concerns included the absence of required care co-ordinator reviews for an amber zoned patient.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the absence of mandatory medical checks for drivers over 70, as the current system relies on self-declaration of medical conditions, which may pose a risk to other road users.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner raised concerns that Ms. Findlay's emergency contact was not informed of her discharge, no follow-up appointment was made, and no contact was attempted for 10 days after she left the hospital.
Addressed to: Priory Hospital
AI-generated concerns summaryThe coroner identified inadequate staff training, no single point of contact, and deficient assessment protocols for trans persons in NHS Trusts. Concerns also included insufficient mental health support for gender identity clinic patients on waiting lists and inadequate clinician liaison.
Addressed to: Barnet Enfield and Haringey Mental Health NHS Trust, NHS England and Tavistock and Portman NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient assessment of Molly's autism diagnosis impact on suicide risk during discharge planning. Concerns were also raised about Essex County Council's failure to act on referrals, conduct assessments, and understand Section 117 Mental Health Act rights.
Addressed to: Essex Partnership NHS Foundation Trust and Essex County Council
AI-generated concerns summaryThe coroner noted the Trust took no further action on known drowning risks at Stewartby Lakes, including unmonitored popular locations and no increased ranger checks in hot weather. Concerns were also raised about insufficient information on water depths and inaccessible safety equipment.
Addressed to: Forest of Marston Vale Trust
AI-generated concerns summaryThe coroner noted an ongoing informal approach to resident supervision and special dietary arrangements at the care home, despite some post-death changes. It was also unclear if staffing levels were sufficient for residents requiring one-to-one care and activities.
Addressed to: Oaks and Woodcroft Care Home
AI-generated concerns summaryThe coroner identified that immediate emergency response protocols were not followed, including delays in activating alarms and calling for an ambulance. Concerns were also raised about inconsistent safety measures for doors in high-risk areas, staff not reporting door closure issues, and the reliability of the Trust's investigation into these matters.
Addressed to: Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays and inaccuracies in falls risk assessments, a confusing observation policy, and a lack of required neurological observations. Concerns were also raised about poor electronic record keeping and communication between staff.
Addressed to: Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner questioned the appropriateness of the British Army presenting fully functional ceremonial daggers to individuals leaving service, noting these are deadly weapons that can remain in the community and some recipients may have mental health issues.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner identified a lack of clear legal power for police to retain keys from a suspect bailed with a condition not to attend their co-owned home, particularly in domestic abuse contexts, which allowed the suspect to force entry.
Addressed to: Minister of State for Crime, Policing and Fire
AI-generated concerns summaryThe coroner noted a lack of standardised information sharing protocols between police forces for cross-border missing persons investigations, which meant crucial details, including possession of a means of suicide, were not consistently relayed.
Addressed to: National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted the severe safety risk of polypharmacy involving gabapentinoids and opiates for patients with iatrogenic drug dependency. There were no active plans by the GP practice to identify and rationalize medication for existing patients at risk.
Addressed to: Hilltops Medical Centre, NHS England, Luton and Milton Keynes Integrated Care Board
AI-generated concerns summaryThe coroner identified safety issues at Porthleven Harbour, noting sections of the harbour wall and pier lacked railings, the pier was poorly lit, and there was an absence of access ladders for individuals who might fall into the water.
Addressed to: Cornwall Council, Porthleven Harbour & Dock Company