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 Mr Yemm's placement in an unsuitable care home, his discharge from hospital despite the home stating they could not accommodate him, and his subsequent fall in a hospital ward.
Addressed to: Adult Social Services, Norfolk County Council and Norfolk and Norwich University Hospital
AI-generated concerns summaryThe coroner noted a lack of consideration for potential fracture injury and absence of imaging following a fall, compounded by over-reliance on pain complaints from a patient with dementia. There was also no serious incident investigation by the Trust after the death.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that the Alternative to Transfer (ATT) service may delay admissions for elderly patients due to an additional layer of telephone triage. There is no adequate audit of its net benefit or research into deaths from delayed admissions where the ATT service was used.
Addressed to: Department of Health and Social Care; NHS Stockport Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that the primary cause of the collision was insufficient visibility available to both drivers at the accident location.
Addressed to: Cornwall Council
AI-generated concerns summaryThe coroner identifies a need to amend the Red Book to include specific advice on postnatal Vitamin D supplementation by Health Visitors. Concerns also include national guidelines not sufficiently directing or providing Vitamin D supplements to at-risk women and babies.
Addressed to: Royal College of Paediatrics and Child Health, Department of Health and Social Care and The National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner notes concerns regarding delays in GPs receiving discharge letters, deeming a three-day delay unacceptable when timely follow-up is required, as such delays risk impacting patient outcomes.
Addressed to: Central Manchester NHS Foundation Trust; Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the investigation into a sexual assault allegation was not conducted by a specialist officer despite the complainant being a child, leading to significant delays. Concerns were also raised about the Metropolitan Police Service's support, which involved a four-day delay in initial contact and minimal assistance.
Addressed to: Home Office; Metropolitan Police Service
AI-generated concerns summaryGaps in care planning for skin integrity and mobility, insufficient documented repositioning, and a failure to recognise deteriorating health led to delayed medical assistance. Additionally, there was a lack of robust management review following the death.
Addressed to: Care Quality Commission; Jubilee Court Nursing Home
AI-generated concerns summaryThe coroner identifies gaps in landlord responsibilities for ensuring ongoing smoke alarm effectiveness and for letting properties without proper consent or inspection. Concerns are also raised about Leeds City Council's practice of awarding Local Housing Allowance without verifying property safety.
Addressed to: Ministry of Housing, Communities and Local Government
AI-generated concerns summaryShooting range staff lacked specific training to identify abnormal behaviour in customers, and there were no periodic emergency response exercises. The coroner noted the national value of such training and exercises for improving safety.
Addressed to: National Rifle Association and National Small Bore Rifle Association
AI-generated concerns summaryThe coroner raised concerns regarding the admission of 16-17 year olds to Leeds Festival without adult supervision, noting the prevalence of illicit drugs and alcohol. The report questioned if allowing this age group access, given they are prohibited from other licensed premises, amounts to an abdication of responsibility by the …
Addressed to: Leeds City Council, Festival Republic Ltd and Live Nation Entertainment PLC
AI-generated concerns summaryThe coroner identified risks from the absence of hard shoulders on smart motorways, motorist confusion, and the need for improved driver awareness. Concerns also included Highways England's ability to identify stationary vehicles and the necessity of a wider smart motorway review.
Addressed to: Department for Transport; Highways England; Secretary of State for Transport
AI-generated concerns summaryThe coroner identified a lack of clear guidance and training for prison staff on the safe use of force when dealing with resistant prisoners who have items in their mouths, which could compromise their breathing.
Addressed to: HM Prison and Probation Service; NHS England
AI-generated concerns summaryThe NHS Pathways script for emergency callers does not sufficiently encourage lone individuals to contact someone to be with them, particularly when delays in paramedic attendance are expected.
Addressed to: NHS Pathways
AI-generated concerns summaryMental health professionals lack awareness of 'Shamanic' hallucinogenic drugs like Ayahuasca and DMT, and their potential to cause or worsen psychosis, leading to sub-optimal patient care. Greater learning is needed as these drugs become more common.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of formal information, training, and distribution of fire drop keys for Dorset Police officers, which prevented them from gaining emergency access to communal properties without delay.
Addressed to: Dorset Police
AI-generated concerns summaryPrescribers issued medication without full information regarding the service user's liver disease, and there was no evidence that a lower methadone dose was considered despite the patient's medical history.
Addressed to: Turning Point
AI-generated concerns summaryThe coroner identified concerns regarding repeated provision of inappropriate food and fluids to a patient despite clear dietary guidance and available information. Staff failed to follow established processes for managing specialist nutritional requirements, and there were delays in implementing necessary dietary signage.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of protocols at Peabody for recording and communicating explicit emergency contact instructions from residents to telecare providers, leading to a family member not being informed after her mother's fall.
Addressed to: Peabody Trust
AI-generated concerns summaryThe coroner identified concerns regarding a frail patient's six-hour wait in a hospital waiting area after a dialysis appointment was reallocated. There was a missed opportunity to contact her family to arrange a temporary return home during this period.
Addressed to: Whipps Cross Hospital