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 identified risks from the absence of hard shoulders or refuge areas on smart motorways, especially during conversion, preventing broken-down vehicles from exiting running lanes. The report also noted the latent risk created by mixing smart and traditional motorway designs.
Addressed to: Highways England
AI-generated concerns summaryThe coroner raises concerns about the effectiveness of constant nursing observation, delays in emergency response due to reluctance to enter a seclusion room, and the junior doctor's insufficient training in resuscitation procedures and unfamiliarity with emergency equipment.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the easy accessibility of websites and forums that openly promote suicide methods, noting insufficient regulation and enforcement action against such platforms.
Addressed to: Minister for Care and Mental Health and National Inquiry into Suicide and Safety in Mental Health
AI-generated concerns summaryThe coroner noted that the resuscitation area was separate from the operating theatre, hindering communication between obstetric and neonatal teams, and that bloods were not readily available in the resuscitation room, potentially causing critical delays.
Addressed to: Mid Cheshire Hospitals NHS Foundation Trust
AI-generated concerns summaryThe Trust did not conduct a detailed investigation into Mr Longshaw's care, and its internal review was flawed, missing opportunities to consider issues related to patients with learning disabilities. Concerns were also raised about the adequacy of education for medical professionals on the practical application of the Mental Capacity Act …
Addressed to: General Medical Council; Great Western Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate wound care knowledge, poor and incorrect wound tracking documentation, and an ineffective referral system with Tissue Viability Nurses. There were also concerns regarding a lack of information on medical cushion use and the availability of correct dressings.
Addressed to: Tadworth Grove Care Home and Tissue Viability Nurses
AI-generated concerns summaryThe coroner noted inadequate support for families of children with rare diseases, with social services refusing assessment and providing limited assistance. Concerns also included a mental health trust's lack of commissioned psychosocial interventions and poor inter-agency communication.
Addressed to: Department of Health and Social Care; NHS Kent and Medway Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted an inadequate investigation of possible bowel perforation, including the use of a limited diagnostic tool and missed signs of sepsis. A surgical opinion was not sought when a patient with post-surgical symptoms attended A&E.
Addressed to: Frimley Park Hospital
AI-generated concerns summaryThe coroner raises concerns about the safety of pedestrians crossing the B4398 (60mph limit) between sections of a towpath, identifying risks from quiet vehicles, pedestrians wearing earphones, and sun glare.
Addressed to: Canal and River Trust; Powys County Council
AI-generated concerns summaryThe coroner identified that Melanie's discharge care package was not followed and considered inadequate, with insufficient planning for changes in her circumstances. Risk assessments prior to leave were not adequate or recorded, and no missing person plan was in place.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe care home lacked continuous oversight, sufficient notes, and a process for recording family concerns. Staff training was inadequate regarding subtle signs of illness and sepsis in the elderly, leading to a failure to recognise and escalate health deterioration.
Addressed to: Roseland Care Home
AI-generated concerns summaryThe coroner raised concerns about incomplete initial triage, inconsistent major trauma protocols, and a prolonged absence of clinical assessment. The report also highlighted limitations in the NHS Pathways tool for managing fluctuating consciousness.
Addressed to: NHS England; South East Coast Ambulance Service
AI-generated concerns summaryThe coroner raised concerns regarding the Medical Priority Dispatch System's algorithm for patients known to have consumed alcohol, specifically whether it includes guidance for clearing airways. Concerns were also noted about the practice of placing an unconscious, vomiting patient onto their back in the absence of clinical support.
Addressed to: Priority Dispatch Corporation
AI-generated concerns summaryThe coroner raised concerns regarding the adequacy of existing safety measures on a bridge and its surrounding area, requesting consideration of further actions to deter dangerous activities and prevent future incidents.
Addressed to: Tennant Investments, Canal and River Trust and Calderdale Council
AI-generated concerns summaryConcerns were raised regarding arrangements for delivering physical prescription documents, which lack effective mechanisms to confirm delivery, detect failure, or remedy non-delivery, thereby risking discontinuity of medical treatment.
Addressed to: Boots UK Ltd; Human Kind Charity
AI-generated concerns summaryThe coroner noted that a substance, easily purchased in relatively small quantities, is classified as a 'reportable poison', which involves less rigorous control measures compared to 'regulated poisons'.
Addressed to: Home Office; Lancashire Constabulary; Senior Coroner for East London
AI-generated concerns summaryThe coroner noted insufficient regulation, warnings, and information to prevent gambling by an addicted individual. Concerns were also raised about inadequate treatment options due to a lack of training for medical professionals, particularly GPs, and insufficient education for young people on gambling harms.
Addressed to: Department for Culture, Media and Sport; Department for Education; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns that the British National Formulary (BNF) guidance was deficient in providing advice for monitoring and identifying sudden pulmonary deterioration in elderly, active patients prescribed Nitrofurantoin for short durations.
Addressed to: Claypath and University Medical Group; National Institute for Health and Care Excellence; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner noted that five-minute observations were recorded at precise, predictable intervals, which could allow individuals to anticipate timings and plan self-harm attempts. There were also concerns regarding a single signature covering multiple observations.
Addressed to: Mersey Care NHS Foundation Trust; Merseyside Police
AI-generated concerns summaryThe text describes the clinical course of events leading to Edward's death following his critical condition at birth, including his mother's care for pre-eclampsia. It does not detail specific concerns identified by the coroner.
Addressed to: Calderdale and Huddersfield Foundation Trust