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 report identifies insufficient training for airline and ground staff regarding the vulnerability of lone passengers disembarked overseas, and a lack of procedures for safeguarding such individuals.
Addressed to: Jet2.com Ltd and Civil Aviation Authority
AI-generated concerns summaryThe coroner noted a lack of written recording for complex medical advice exchanged between consultants, potentially leading to a misunderstanding of the advice's basis and importance.
Addressed to: NHS Improvement, Royal College of Physicians, Royal College of Surgeons, General Medical Council and St. Peter’s Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the nature and extent of basic life support and first aid training provided to Gwent police staff, particularly for those in regular contact with individuals who are unwell or injured and may develop respiratory problems.
Addressed to: Gwent Police
AI-generated concerns summaryThe coroner raises concerns about websites advocating methods of taking one's life, including advice on using prescription medications, and the easy online availability of toxic substances without safeguards.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted limited documentation and observations at the care home, an unclear COVID-19 origin due to no admission risk assessment, and staff confusion over PPE guidance. Ambulance delays also impacted the transport of vulnerable patients to acute settings.
Addressed to: Care Quality Commission, Vicarage Residential Care Home, PH England, NHS England and Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner noted a lack of clear assurance that both parents understood safe sleeping advice, as health visitors did not ask for descriptions of arrangements. Concerns also included reduced health visitor services due to COVID-19 redeployment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted insufficient physical prevention for pedestrians to enter the Busway lanes and a lack of clear signage, with multiple fence gaps providing easy access. Concerns were also raised about apparent design flaws and a lack of preventative actions despite previous serious incidents.
Addressed to: Luton Borough Council
AI-generated concerns summaryThe coroner identified concerns about the risk of patients absconding from Laurel Ward due to a scalable fence and unrestricted garden access. Dense shrubbery in the garden was noted to provide concealment for various items, and there was a lack of regular searches, limited observation, and no CCTV.
Addressed to: Midlands Partnership NHS Foundation Trust
AI-generated concerns summaryThe absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, fluid management, and post-operative care, endangering patients.
Addressed to: British Association of Aesthetic & Plastic Surgeons, British Association of Plastic, Reconstructive & Aesthetic Surgeons and National Institute for Care Excellence
AI-generated concerns summaryThe coroner noted concerns regarding relatively easy access over the footbridge parapet and sides at the location, which had not been remedied.
Addressed to: Highways Agency Essex County Council
AI-generated concerns summaryThe coroner noted that Mr Bardoliwalla had accumulated prescribed controlled medication and there was no process for collecting and disposing of this medication.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns were raised that a specific Code of Practice and British Standard 5839 LD1 Maximum Protection level for fire detection were not statutory requirements.
Addressed to: Ministry for Housing and Local Government
AI-generated concerns summaryThe coroner identified a lack of a safe medication storage system for residents requiring supervision, noting the deceased could easily access a locked cupboard and subsequently overdosed. Additionally, the investigation into the incident was perfunctory and conducted by untrained staff.
Addressed to: City and County Healthcare Group; Comfort Call; Stoke on Trent City Council
AI-generated concerns summaryA police officer did not share crucial information from a bus driver with medical staff, and officers also did not share Ms Marchessou's statements. Issues included no Merlin record of vulnerability and one officer's limited reflection on the incident.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner identified two misdiagnoses at Warwick Hospital, despite specific GP instructions, and noted difficulties with the GP team accessing electronic records due to slow scanning of patient notes.
Addressed to: Warwick Hospital
AI-generated concerns summaryThe coroner noted the widespread availability of illegally dealt prescription drugs to vulnerable individuals and inquired about projected or actual steps to prevent medication diversion from lawful dispensing to criminal hands.
Addressed to: Home Office; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner identified a lack of safeguards when a patient's suicide risk was downgraded by a psychiatric liaison nurse without consultation with the referring GP or a second psychiatric opinion.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryDifferent healthcare departments maintained separate patient care records and lacked inter-departmental communication, requiring professionals to rely on their own initiative to gather crucial patient information.
Addressed to: NHS Digital; NHS England
AI-generated concerns summaryThe coroner noted insufficient clarity in EEAS training for identifying police attendance and sharing risk information, along with communication protocols between EEAS and Essex Police for joint responses. Concerns were also raised about the clarity of blue lights response training for Essex Police and the arrangements for urgent mental health …
Addressed to: EFAS; Essex Partnership University NHS Foundation Trust; Essex Police
AI-generated concerns summaryThe coroner noted the absence of an approved safe loading and lifting plan, a banksman to supervise heavy loads, and a clearly marked safe area for lorry drivers. PCR Steel also lacked the correct equipment for moving and loading products safely.
Addressed to: PCRSteel Ltd; SE Galvanisers