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 identified a lack of a safe system, training, and compliance auditing for using the NEWS2 assessment tool for acutely unwell patients in a secure setting, leading to an inconsistent application and awareness among staff.
Addressed to: HMP Nottingham, Forensic Services Nottinghamshire Healthcare NHS Foundation Trust and TTP-UK
AI-generated concerns summaryThe coroner raised concerns regarding unclear and unsafe systems for GPs to contact mental health teams for urgent reviews, and patients in crisis being expected to initiate contact. GPs' awareness of how to request urgent psychiatric reviews was also noted as an issue.
Addressed to: Hereford and Worcester Health and Care NHS Trust and Hereford and Worcestershire ICB
AI-generated concerns summaryThe coroner raises concerns about a lack of clarity regarding which government department will be responsible for monitoring and preventing the sale of DNP for human consumption once it is added to the Poisons Act. This lack of clarity could delay an effective response to advertisements for the substance.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified a lack of understanding of specific sepsis signs among family and patients, which may have delayed emergency calls. The report suggests providing information cards on sepsis signs to patients with PEGs or known infection risk in the community.
Addressed to: Cardiff and Vale University Health Board NHS Trust and Abbott Nutrition
AI-generated concerns summaryThe coroner identified concerns regarding the regulation and assessment of car strength where safety harnesses and their reinforcement plates are attached, after a crotch strap reinforcement plate pulled through the car floor during an overturn.
Addressed to: Regulatory Counsel and Disciplinary Officer
AI-generated concerns summaryThe coroner noted a lack of evidence for a multi-agency planning meeting prior to discharge and no clear procedures for safely discharging patients with multiple complex health and social care needs.
Addressed to: East Kent Hospital University NHS Foundation Trust; Kent and Medway NHS and Social Care Partnership Trust; Forward Trust
AI-generated concerns summaryThe coroner identifies gaps in police training, noting a lack of clarity on what constitutes "prolonged" restraint and its applicability during arrest. Further concerns relate to training content that provides potentially inaccurate expectations regarding ambulance response categorisation and medical interventions.
Addressed to: Thames Valley Police, College of Policing, South Central Ambulance Services and Association of Ambulance
AI-generated concerns summaryThe coroner notes increasing e-scooter fatalities on public roads, linked to reduced enforcement and a lack of mandatory head protection for riders. There are also concerns about inconsistent and non-prominent warnings from manufacturers regarding illegal use.
Addressed to: Major retailers of e-scooters; Mayor of London; Metropolitan Police Service; Transport for London
AI-generated concerns summaryConcerns were raised about a specific location on the M20 motorway prone to collisions caused by aquaplaning, where poor road camber leads to water running across the carriageway during heavy weather. Remedial works are needed to address the drainage issues at this site.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted inadequate mental health training for police officers and their understanding of support services. Concerns were also raised about the REBOOT scheme lacking provision for vulnerable individuals nearing 18, which prevented early intervention.
Addressed to: Sussex Police; Sussex Police and Crime Commissioner
AI-generated concerns summaryThe coroner raised concerns about HMP Wealstun's lack of night-time healthcare staff and insufficient CPR and defibrillator training for night patrol officers. There is also no express direction for officers to perform CPR on unresponsive prisoners pending medical arrival.
Addressed to: HM Prison Wealstun; Ministry of Justice
AI-generated concerns summaryA worn-down kerb at a junction, not deemed for repair by the council, creates an unsafe entry point for vulnerable road users, who may mistake it for an official crossing and struggle to leave the carriageway.
Addressed to: Highways and Infrastructure, Birmingham City Council
AI-generated concerns summaryStaff left Ms Brown's medication unsecured despite an identified risk that she might take an incorrect amount, and the digital care application lacked instructions on keeping the medication in a secure box.
Addressed to: Chief Coroner
AI-generated concerns summaryThe coroner raised concerns regarding the accessibility of the bridge's parapet and railing, the absence of monitored CCTV and lighting to detect individuals at risk, and the inherent danger of falls from the bridge.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner identified insufficient funding for the police force to meet increased summer demand, leading to inadequate staffing levels for call handlers, resource deployment officers, and uniformed officers. This resulted in calls not being answered or responded to within adequate timeframes, a problem noted to have persisted for a decade.
Addressed to: Devon and Cornwall Constabulary
AI-generated concerns summaryConcerns were raised regarding the absence of a pressure-relieving bed arrangement prior to discharge and a lack of clear communication and coordination among hospital, district nurses, and carers concerning daily skin integrity checks for a patient at high risk of pressure ulcers.
Addressed to: University college London Hospital NHS Trust, Central London Community Healthcare NHS Trust, City of Westminster Council and Registered Care Manager
AI-generated concerns summaryThe coroner noted that persistent understaffing at the care home affected staff's ability to provide safe care and treatment, and also limited management's capacity to monitor care appropriateness.
Addressed to: Home Farm Trust Limited
AI-generated concerns summaryThe social work team did not conduct renewed home visits, seek updated information from the family, or liaise with mental health services after receiving new information about a carer's mental health. This led to undue reliance on old investigations and assessments, potentially missing critical details of the carer's illness.
Addressed to: Buckingham Council Children’s Services
AI-generated concerns summarySenior nursing staff did not appear to appreciate the importance of comprehensive, holistic care plans or assessments of capacity to refuse observations. Additionally, some nurses did not recognise the acute clinical severity of the patient's condition and failed to respond with necessary urgency.
Addressed to: North East London Foundation trust
AI-generated concerns summaryA probation officer unilaterally removed a licence condition requiring mental health appointments for a high-risk individual, without consulting MAPPA professionals or mental health practitioners. This lack of consultation could risk future deaths.
Addressed to: Addressees have not been indexed.