Browse 6,471 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 summaryConcerns were raised regarding the availability of various resources providing information and assistance related to suicide, which were accessed by the deceased and other individuals prior to their deaths.
Addressed to: Department for Digital, Culture, Media & Sport; Home Office; Joint Select Committee for the Draft Online Safety Bill
AI-generated concerns summaryThe coroner requested an urgent review of safety measures at the site, including warning signs, throw ropes, and buoys where the water deepens. Consideration was also sought for applying similar safety approaches used for tidal waters to non-tidal waters, especially in publicly accessible areas.
Addressed to: Environment Agency and National Trust
AI-generated concerns summaryThe coroner identified challenges with information sharing due to a lack of interoperability between patient record systems across NHS trusts. Additionally, police forces lack automatic mechanisms to share welfare and health information about individuals.
Addressed to: Department of Health and Social Care, Home Office; National Police Chiefs’ Council; NHS England; Yeovil District Hospital
AI-generated concerns summaryCollege of Policing training materials lack guidance on managing acute behavioural disturbances due to temporal lobe epilepsy, particularly concerning the use of restraint. The coroner suggested including this in mandatory annual restraint refresher training for officers.
Addressed to: National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted the absence of written safety policies for guests and specific venue risks, along with insufficient documentation of shared responsibilities with other event providers.
Addressed to: Bounce Til I Die
AI-generated concerns summaryThe coroner noted the need for the trust to adopt a single system for drug record keeping and monitoring, incorporating administration limits, wider implementation of safety software, and flagging discrepancies between prescribed and administered drugs.
Addressed to: Oxford University Hospitals NHS Foundation Trust; John Radcliffe Hospital
AI-generated concerns summaryThe coroner raised concerns about the slow progress of the Army's Suicide Prevention Group in strategy and risk factor identification. Also noted was the need for regular mental health screening for soldiers and better awareness of handling service complaints.
Addressed to: Army Headquarters
AI-generated concerns summaryThe coroner raised concerns that reliance on remote contacts and lack of drug testing made accurate assessment and support of clients difficult, increasing risks from excessive dosage or polydrug exposure. This highlights a need for more effective supervision.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust and Humankind
AI-generated concerns summaryThe coroner noted concerns regarding inaccurate patient observation records due to charts being pre-populated and electronic timings manually overwritten. There are also gaps in standardised observation charts and time-entry requirements for unregistered mental health ward staff.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding persistent staffing shortages at Clifton Hospital, a rehabilitation facility, which results in staff not having enough time to carry out expected tasks and places elderly and vulnerable patients at risk.
Addressed to: Department of Health and Social Care; Nottinghamshire County Council; Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Immigration Officers had not received specific training in pursuit procedures or decision-making for stressful situations, which the jury indicated could have contributed to the death.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted an absence of local guidance for GPs regarding the safe oversight of multiple high-dose analgesic prescriptions in the community and when referral to a pain specialist is required.
Addressed to: Trafford Clinical Commissioning Group and Greater Manchester Health & Social Care Partnership
AI-generated concerns summaryThe coroner noted that current regulations do not mandate the fitting of Crash-Resistant Fuel Systems (CRFS) in all rotorcraft, particularly as a retrofit, increasing the risk of post-crash fires. There is also no central register to inform the public whether an aircraft is fitted with CRFS.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner identified a lack of a commissioned specialist service for ASD patients requiring long-term dietetic support for ARFID symptoms. Existing dietetic, eating disorder, and learning disability services did not meet the criteria for these patients.
Addressed to: Nottingham and Nottinghamshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted a 19-minute delay in the prison control room providing specific information to the ambulance service, impacting dispatch. There was also no direct communication method between ambulance call centre staff and prison staff providing CPR, which impeded guidance and information exchange.
Addressed to: HM Prison Cardiff
AI-generated concerns summaryThe PSNI's inadequate recording of critical mental health concerns from medical professionals and family led to crucial information not being relayed between police forces and hospitals, indicating an insufficient systemic safety net for vulnerable individuals.
Addressed to: Police Service of Northern Ireland Belfast
AI-generated concerns summaryPolice and social services did not consistently recognise or record knife possession and gang affiliation as risk factors in assessments. Concerns were also raised about the Metropolitan Police Service's Child Safety Unit workload and capacity to effectively fulfil safeguarding roles.
Addressed to: University of Gloucestershire, University of Durham, Metropolitan Police Service and Mayor of London
AI-generated concerns summaryThe coroner identified a lack of clear guidance for police to record and cascade relevant information from MARAC meetings to officers, leading to critical information not reaching the firearms team. Concerns were also raised regarding officers' confusion about rescue breaths during CPR and the absence of a policy for appointing …
Addressed to: College of Policing; West Midlands Police
AI-generated concerns summaryThe coroner notes that military personnel and their dependents receiving inpatient secondary care overseas may receive post-operative treatment, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted a concern that patient sensitivities to antibiotics might be ignored, leading to administration of the antibiotic even when there is a known potential low risk.
Addressed to: Bradford Teaching Hospitals NHS Trust