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 noted that the lack of enforceable requirements for clear signage for accessible toilet facilities, which was a directly contributory factor in a death, could lead to similar incidents in other public buildings.
Addressed to: Minister of State for Disabled People, Health and Work and Minister of State for Business, Energy and Industrial Strategy
AI-generated concerns summaryNursing care plan risk assessments, particularly for falls, were not consistently updated, and documentation practices remained poor due to time pressures. Additionally, no designated individual on the ward held overall responsibility for ensuring adherence to the hospital's hydration policy.
Addressed to: Chief Coroner - PFD Reports; Queen Alexandra Hospital
AI-generated concerns summaryThe emergency department's significant overcapacity causes delays in transferring patients from ambulances, as well as an insufficient safety check mechanism for patients in ambulances, which contributed to delayed diagnosis.
Addressed to: Department of Health and Social Care; Norfolk and Waveney Integrated Care Board
AI-generated concerns summaryThe coroner noted inadequate training for prison staff on the adult safeguarding policy, particularly for self-neglect. There is also a gap in escalation processes for self-neglect issues, as existing routes focus on violence and self-harm.
Addressed to: Minister of State, HM Prison and Probation Services
AI-generated concerns summaryThe coroner notes a lack of regulations governing the storage and handling of Oramorph in community settings, unlike in institutional settings, and no requirement for recipients to keep it safe from others.
Addressed to: Home Office; Medicines and Healthcare Products Regulatory Agency; National Institute for Health Care Excellence
AI-generated concerns summaryThe coroner noted large projects with work at height lacked mandatory statutory agency notification and inspection. Principal contractors also have no mandatory requirement for accredited health and safety training, either before or after incidents.
Addressed to: Department for Work and Pensions; Health and Safety Executive
AI-generated concerns summaryThe coroner identified a continuing risk of aquaplaning incidents and future deaths on the M25 due to a persistent flat spot on the road. A comprehensive risk management plan for the location is pending a decision on addressing this issue.
Addressed to: Connect Plus (M25) Limited; Department for Transport; National Highways Limited
AI-generated concerns summaryThe report raises concerns about Alexandra Care Home's medication management and supervision, with no explanation for the excessive oxycodone found in Mrs Ellison, and the systems remaining unchanged since her death.
Addressed to: CQC, Weightmans’s Solicitors and Four Seasons Health Care
AI-generated concerns summaryThe coroner noted issues with initial treatment decisions being made by inexperienced practitioners without senior oversight and patients being discharged quickly for missed appointments, often without their current circumstances or input from other agencies being established.
Addressed to: Herefordshire and Worcestershire Healthy Minds
AI-generated concerns summaryHeavy rainfall leads to surface water convergence on the A390 from Coliza Hill, increasing aquaplaning risks at the incident location. Feasible road drainage improvements, which could mitigate this risk, have not been implemented despite a prior similar incident.
Addressed to: Cormac and Cornwall Council
AI-generated concerns summaryInsufficient staff on duty in the SACU meant medical assessments were not undertaken for the deceased. A single officer on duty also caused a delay in emergency response due to the three-man unlock requirement.
Addressed to: Ministry of Justice; HM Prison and Probation Service
AI-generated concerns summaryThe coroner raised concerns regarding the absence of mandatory safety advice at the point of retail sale for paddleboards, specifically concerning the wearing of life-saving equipment and appropriate leash selection for different water conditions.
Addressed to: Prime Minister’s Office; Tesco PLC
AI-generated concerns summaryThe coroner noted inadequate communication and information sharing between seven different healthcare organisations, each using separate clinical record systems, which prevented crucial patient information, such as Community Treatment Order status, from being accessible to all providers.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted inadequate and poorly placed signage at waterfalls, particularly at points where individuals might enter the water. Signs lacked clear warnings about water dangers and the risk of drowning for non-swimmers, with existing signage being overloaded and not easily understandable.
Addressed to: Brecon Beacons National Park Authority, Natural Resources Wales, Neath Port Talbot Council, Powys County Council and Rhondda Cynon Taf County Borough Council
AI-generated concerns summaryNurses, particularly those newly qualified, are not trained in the Multifactorial Risk Assessment process, a key component of the falls prevention policy, before assuming patient care responsibilities.
Addressed to: Health Education and Improvement Wales
AI-generated concerns summaryThe Greater Manchester Police Incident Response Policy lacks specific guidance preventing the referral of incidents to third parties without police attendance, potentially leading to police not responding within required timescales.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner noted the need for a national audit of emergency oxygen delivery and the formulation of new guidelines to enhance national practice. There was also a call for specific guidance on fitness to fly from a respiratory perspective in the context of trauma, as current guidance does not cover …
Addressed to: British Thoracic Society; Healthcare Quality Improvement Partnership Ltd
AI-generated concerns summaryThe coroner noted the absence of pre-treatment spinal imaging, meaning a patient's ossification was unknown before mobilisation after they experienced loss of sensation. Consideration was also raised regarding mandatory First Aid training for chiropractors.
Addressed to: General Chiropractic Council
AI-generated concerns summaryThe coroner notes a lack of research into why motorcyclists' helmets come off or rotate during collisions, and raises concerns about the absence of checks for correct helmet sizing and insufficient rider education.
Addressed to: Department for Transport; Transport Research Laboratory
AI-generated concerns summaryHull Royal Infirmary staff lacked understanding and incorrectly implemented Section 5(2) of the Mental Health Act 1983, with invalid paperwork. The coroner noted a need for wider awareness and training for doctors and nurses on MHA holding powers.
Addressed to: NHS England, Chief Coroner, Royal College of Psychiatrists, Royal College of Nursing, NHS Scotland and NHS Northern Ireland