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 that privately rented accommodation in the London Borough of Wandsworth lacks a registered landlord scheme, meaning smoke and carbon monoxide detectors are not required. This absence increases the risk of death from fire or CO exposure for residents.
Addressed to: London Borough of Wandsworth
AI-generated concerns summaryBabies at increased risk of early neonatal collapse following complicated deliveries are not provided with enhanced monitoring on the postnatal ward, leading to a lack of early detection should collapse occur.
Addressed to: London North West University Healthcare NHS Trust
AI-generated concerns summaryThe coroner raises concerns that accepting a 'grunt' as a verbal response during prison welfare checks does not fulfil the requirement for an adequate verbal response, limiting a prison officer's ability to properly assess a prisoner's welfare. This practice could risk future deaths due to insufficient information.
Addressed to: HMP Guys Marsh Prison
AI-generated concerns summaryThe coroner noted that older versions of anti-ligature clothing, which the deceased used to form a ligature, remain in circulation and may provide false reassurance to staff regarding self-harm risk, despite subsequent product improvements by the manufacturer.
Addressed to: Interweave
AI-generated concerns summaryA general practitioner miscalculated a patient's clot risk by misinterpreting family history guidelines and did not assess cardiovascular risk due to overlooking a section in the medical eligibility criteria.
Addressed to: Faculty of Sexual and Reproductive Healthcare (FRSH) Royal College of Obstetricians and Gynaecologists; Lathom Road Medical Centre
AI-generated concerns summaryThe coroner identified delays in urgent fetal growth restriction scans due to capacity issues and a lack of understanding of FGR risks among non-specialist professionals and parents.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns that the Trust's Clinical Risk Policy lacks explicit guidance on identifying a service user's living location and detailed procedures for documenting, discussing, and reporting disclosures of offensive weapons to police.
Addressed to: Dorset Healthcare University NHS Foundation Trust
AI-generated concerns summaryThe coroner requested consideration be given to reviewing the appropriateness of a practice.
Addressed to: Spire Harpenden Hospital
AI-generated concerns summaryThe Urgent GP Care Centre experienced issues with a non-mandatory sepsis template, confusion in out-of-hours patient referral pathways to hospital specialities, and a failure to record and communicate key patient observations.
Addressed to: Atrumed Ltd and Bedfordshire Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that critical information regarding the deceased's chloramphenicol sensitivity, documented since 1997, was not accessible or flagged to clinicians during a later hospital admission, resulting in the medication being prescribed.
Addressed to: Portsmouth Hospitals NHS Trust
AI-generated concerns summaryA requested review of the patient's multiple medications was not undertaken, and the Surgery could have considered alternative pain management earlier to prevent overdose risks.
Addressed to: Alvaston Medical Centre
AI-generated concerns summaryConcerns included ineffective bin locks not designed to prevent entry, the absence of an automated system to detect unusually heavy bins, and poor visibility through lorry viewing windows which hindered drivers from safely checking contents.
Addressed to: British Standards Institute, Container Handling Equipment Manufacturers Association, Dennis Eagle Ltd and Biffa Waste Services Ltd
AI-generated concerns summaryThe coroner noted insufficient safeguarding review and senior clinical oversight. Additionally, there was a lack of staff awareness regarding the VTE policy, with no regular audit or training program for its implementation.
Addressed to: GMMH NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the failure to appoint a Care Co-ordinator, which may have contributed to the death. There were also significant staffing shortages in the North Warwickshire area, with levels 65% below recommended as of March 2022.
Addressed to: Coventry and Warwickshire Partnership NHS Trust
AI-generated concerns summaryThe coroner identified insufficient specific guidance for General Practitioners on managing patients with eating disorders who are unwilling to engage with treatment. This can leave GPs unsure how to provide necessary care.
Addressed to: British Association for Counselling and Psychotherapy; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of understanding among care home staff and call operators regarding when a DNACPR order should not be applied, indicating a need for further training and clarification.
Addressed to: Association of Ambulance Chief Executives and Nursing and Midwifery Council
AI-generated concerns summaryThe coroner is concerned that staff may not apply the correct test under the Mental Capacity Act 2005 when deciding on medication in similar circumstances, creating a risk of future deaths.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe report highlights a delay in actioning recommendations for Mental Health Act S2 assessments, specifically an 8-day gap in Joshua's case, due to Approved Mental Health Professional allocation. Such delays are reportedly not unusual and may place individuals at risk.
Addressed to: Sheffield Health and Social Care NHS Foundation Trust
AI-generated concerns summaryThe electronic prescribing tool permitted bypassing allergy sections and there was insufficient knowledge of drug constituents, leading to prescribing errors. These issues were not identified by hospital staff during discharge or by a GP, including an Amiodarone dosage error.
Addressed to: Cwm Taf University Morgannwg Health Board
AI-generated concerns summaryThe coroner raised concerns about the prevalence of illegal commercial flights for reward, particularly in the sports and music industries, which do not meet safety standards. There are also concerns about the Civil Aviation Authority's limited powers to secure evidence, which hampers investigations and prosecutions of such flights.
Addressed to: British Chambers of Commerce; British Horseracing Authority; Confederation of British Industry; Department for Culture, Media and Sport; Department for Transport; England and Wales Cricket Board; English Football League; Executives’ Association of Great Britain; Football Association; Institute of Directors; Jockey Club; Lawn Tennis Association; Motorsport UK; Non-Executive Directors’ Association; Premier League; Professional Footballers’ Association; Rugby Football League; Rugby Football Union; UK Athletics; UK Sport