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 summaryThe coroner identified that the employee worked on a roof without prior experience or mandatory safety training. There was an absence of designated supervision and a structured training programme for new or unqualified employees.
Addressed to: Wayne Clarey Roofing & Cladding Ltd and Health & Safety Executive
AI-generated concerns summaryThe coroner noted excessive delays in handing over patients from ambulances to Royal Stoke University Hospital, with some waits exceeding four hours, impacting the ambulance service's ability to attend to other patients.
Addressed to: Royal Stoke University Hospital and NHS England
AI-generated concerns summaryThe coroner noted a missed opportunity to provide care for a dual diagnosis patient and identified gaps in inter-agency communication, including reciprocal record access. Concerns were also raised about patients being easily discharged without assertive engagement or referral to other agencies.
Addressed to: Cornwall Council; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified lengthy delays for students at the University of South Wales in accessing mental health support services, even when suicidal ideation was expressed and risk factors like ASD were known.
Addressed to: University of South Wales
AI-generated concerns summaryThe deceased was able to leave the service premises unsupervised and obtain drugs, breaching the service's own rules. Additionally, a serious incident review into the supervision failures had not been undertaken by Free the Way.
Addressed to: Free the Way
AI-generated concerns summaryNICE Guidance NG121, which relates to intrapartum care, lacks a clear national definition for a "large-for-gestational-age baby." This absence leads to inconsistent application of the guidance across NHS Trusts and by clinicians when considering delivery modes.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner raised concerns regarding the complex and potentially misleading system for sharing examination results, including the delayed ratification of provisional passes. There was also a lack of a system for personal tutors to contact vulnerable students prior to the release of failed examination results.
Addressed to: Cardiff University
AI-generated concerns summaryThe coroner identified a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotics prescribed by a GP at the hospital's request for patients undergoing regular review. This unclear pathway presents a risk of future deaths.
Addressed to: North West Anglia NHS Foundation Trust, Cambridgeshire and Peterborough Clinical Commissioning Group and Department for Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the unreliable fire detection system in prison cells, which cannot detect fires sufficiently early. Despite previous recommendations and knowledge of rapid fire progression, effective in-cell automatic fire detectors have not been installed.
Addressed to: Minister of State for Prisons and Probation, Ministry of Justice
AI-generated concerns summaryThe Health Board did not review an Action Plan as scheduled, which is a recurring issue where the Board fails to complete its own actions within set timeframes. The coroner noted that this lack of follow-through with recommendations puts lives at risk.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted that internal hospital referrals were paper-based and not routinely placed on patient notes until days before clinic, risking clinicians not having full patient referral information readily available.
Addressed to: Cwm Taf University Health Board
AI-generated concerns summaryThe coroner noted concerns that the alcohol policy for Op Cabrit was not realistic, workable, or widely understood, and that the "shark watch" role, intended to ensure soldier vigilance, was not formalised or effectively implemented.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted insufficient mandatory radio communication between ground crew and glider pilots meant observed problems before launch were not effectively communicated. The report suggests the Civil Aviation Authority consider requiring such communication and the British Gliding Association strengthen its guidelines.
Addressed to: Civil Aviation Authority and British Gliding Association
AI-generated concerns summaryThe coroner raised concerns that maternal wishes regarding mode of delivery were not sufficiently prioritised, with inadequate recorded discussions on options and risks. There was also a lack of specific guidance on managing infection risk from a retained foetus following feticide.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the hospital trust's reliance on agency nursing staff and sought information on measures to reduce this dependence. They also inquired about national plans to address the ongoing shortage of nursing staff.
Addressed to: Department of Health and Social Care; Frimley Park Hospital
AI-generated concerns summaryThe coroner noted poor documentation of Mr Hunter's diet and weight, an incorrect BMI calculation that led to an inaccurate MUST score, and a failure to follow NICE guidance on weight monitoring.
Addressed to: Stockport NHS Trust
AI-generated concerns summaryThe coroner identified challenges in the Emergency Department due to a lack of night-time consultant cover and insufficient supervision for junior doctors, especially those new to the department. The report also noted inconsistent documentation of supervisory discussions between clinicians.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified significant delays in gynaecological referrals from GPs to secondary care, alongside insufficient understanding of heavy premenstrual bleeding guidance in General Practice. Concerns were also raised about poor GP referral documentation and the absence of clear systems for referral follow-up.
Addressed to: Department of Health and Social Care; Tameside Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns about the lack of continuity in District Nurse care, absence of photographic wound documentation, and inability to access electronic records during home visits, potentially hindering recognition of deteriorating patient conditions elsewhere.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe decision to rescind the patient's section was made without family involvement or a formal mental capacity assessment, alongside poor treatment continuity. Subsequently, concerning behaviours and family warnings were not sufficiently considered to reassess his voluntary patient status.
Addressed to: Leeds and York Partnership NHS Foundation Trust