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 raised concerns regarding the design of a road junction where drivers frequently cut the corner and sun glare reduces visibility, contributing to multiple collisions. It was suggested a pedestrian refuge and 'keep left' sign could prevent future accidents.
Addressed to: Plymouth City Council
AI-generated concerns summaryThe coroner raised concerns about the three-hour delay in ambulance response for an elderly patient with significant trauma, noting that such delays could put future lives at risk despite ongoing plans to improve responsiveness.
Addressed to: Wales Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner raised concerns that severe Acute Behavioural Disturbance (ABD), a condition posing a high risk of sudden death, is currently categorised as a Category 2 ambulance response. Expert evidence indicates a Category 1 response is needed for prompt hospital transfer.
Addressed to: College of Paramedics, The Association of Ambulance Chief Executives, NHS Pathways and Advanced Medical Priority Dispatch
AI-generated concerns summaryThe coroner identified gaps in policy adherence, staff recruitment, training, and appraisals at the care home. Concerns were also raised regarding the effectiveness of auditing processes and the candour of internal investigations.
Addressed to: Care Quality Commission; Four Seasons Healthcare
AI-generated concerns summaryThe coroner identified a lack of sterile replacement catheters and inadequate fluid monitoring records at the nursing home, which management failed to detect. Concerns were also raised regarding a missing handover record and insufficient management checks on record keeping.
Addressed to: Copperfields Nursing Home; Department of Health and Social Care; Quality and Exemplar Healthcare
AI-generated concerns summaryThe application form lacks a separate, explicit option for disclosing mental health illness, distinct from 'disability' or 'special needs'. This omission may discourage applicants from providing information and receiving appropriate support.
Addressed to: Universities and Colleges Admissions Service
AI-generated concerns summaryThe care home lacked qualified nursing staff to reinsert a time-critical RIG tube for a resident with complex needs. Concerns were also raised about staff clinical judgment regarding critically ill patients who required urgent medical attention.
Addressed to: Holmes Care Group Limited
AI-generated concerns summaryA dispute over land maintenance responsibility between Great Yarmouth Borough Council and Caister-On-Sea Parish Council has led to overgrown grass, which obstructs the view of Coastwatch volunteers and led to a volunteer undertaking unsafe grass cutting.
Addressed to: Great Yarmouth Borough Council and Caister-On-Sea Parish Council
AI-generated concerns summaryThe coroner noted that medication from a previous cell occupant was found in Mr Habib's cell, and identified a disconnect between HMP Swaleside's local policy and the Prison Officer's understanding.
Addressed to: HMP Swaleside
AI-generated concerns summaryWarwickshire police did not act on two requests from hospital staff to identify an unconscious patient, which prevented the hospital from accessing his previous medical history that could have assisted his treatment.
Addressed to: Warwickshire Police
AI-generated concerns summaryThe coroner identified inadequate communication between prison healthcare personnel and both the prison control room and ambulance control during medical emergencies. This recurring issue in Lancashire prisons suggests a potential national problem.
Addressed to: HMP Preston; HMPPS
AI-generated concerns summaryThe coroner identified inadequate leadership and supervision in police investigations, resulting in basic errors like unperformed intelligence checks and forensic omissions. Concerns were raised about a potential persistent lack of ownership for investigations despite training.
Addressed to: Metropolitan Police Service, National Police Chiefs’ Council, College of Policing and DCMS
AI-generated concerns summaryThe coroner raised concerns regarding unclear sedation documentation, delayed recognition of a patient's declining condition, and difficulties reaching a duty doctor. Delays in calling paramedics and their access to the ward were also noted.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inadequate transition arrangements within ELFT for individuals with high-functioning autism moving from child to adult services, leading to a lack of appropriate mental health care and social support. Concerns were also raised that this service gap might exist nationally.
Addressed to: East London NHS Foundation Trust; NHS England
AI-generated concerns summaryThe Home Detention Curfew Policy permits early release directly from segregation units for prisoners deemed too risky for the general population. It also lacks a broad assessment of a prisoner's risk of harm to others and a framework for multi-agency information sharing.
Addressed to: Minister of State for Prisons and Probation
AI-generated concerns summaryThe coroner noted paramedics' apparent lack of training in buccal midazolam and other oxygenation techniques, alongside the absence of suction attempts. Concerns were also raised about East Midlands Ambulance Service not accepting a recommendation to carry and administer buccal midazolam.
Addressed to: East Midlands Ambulance Service
AI-generated concerns summaryThe coroner notes differing guidance on IV fluid bolus volumes for children in shock and suggests reconsidering intensive care escalation, alongside the need for guidance on balancing antibiotic risks in bacterial gastroenteritis with suspected sepsis.
Addressed to: National Institute for Health & Care Excellence
AI-generated concerns summaryA flaw in the electronic patient record system (EMIS) means double-clicking 'file no comment' can inadvertently file unreviewed radiology results, potentially causing urgent findings to be overlooked. This could lead to lost opportunities for treatment and future deaths.
Addressed to: North Cumbria Integrated Care NHS Foundation Trust and EMIS Group
AI-generated concerns summaryThe coroner identified a significant breakdown in communication, trust, and respect between primary and secondary care. This left vulnerable patients without appropriate information and support, exemplified by a GP not directly addressing discharge concerns with hospital staff.
Addressed to: Aneurin Bevan University Health Board and Richmond Clinic
AI-generated concerns summaryThe coroner raised concerns that non-medically qualified social workers conducted home assessments, missing opportunities to obtain expert medical advice on medication interactions for the deceased.
Addressed to: NHS England and Essex Partnership University Trust