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 summaryAllison did not receive a pre-surgical discussion before consenting to major thoracic surgery, and nursing staff did not escalate vital signs monitoring or consistently seek clinical review following non-reassuring results post-surgery.
Addressed to: Bradford teaching hospitals NHS Trust
AI-generated concerns summaryVariations in parenteral nutrition management and communication were identified for patients with medical conditions overseen by other hospitals. The coroner noted the need for a named local consultant and for specialist departments to be consulted upon admission.
Addressed to: Wye Valley NHS Trust
AI-generated concerns summaryThe coroner identified a need for better systems to ensure organisations provide sufficient detail on safeguarding concerns and medical needs for individuals entering accommodation. There was also a concern about safeguarding matters not being logged with the hub if an individual was about to be deported.
Addressed to: G4S; Home Office; Urban Housing Services
AI-generated concerns summaryThe coroner identified concerns regarding the HGV's lack of a warning device, insufficient driver training on reporting roadside hazards to emergency services, and the rear hazard warning light being difficult to see and lacking redundancy.
Addressed to: DAF Trucks Ltd; DVSA; Office of the Traffic Commissioner; Road Haulage Association; Whitelock Development; Whitelock Plant Limited
AI-generated concerns summaryNursing staff did not follow the Trust's irregular observation policy, which was also misunderstood by ward management and the lead investigator. The coroner also noted delays of up to 24 hours in record-keeping, affecting information availability.
Addressed to: North West Boroughs Healthcare NHS Foundation Trust
AI-generated concerns summaryStaff were unable to access vital patient information recorded in electronic notes, impacting care decisions. The coroner identified a need to review the notes system's effectiveness, staff training, and how information is recorded and retrieved.
Addressed to: Milton Keynes Hospital
AI-generated concerns summaryThe coroner identified gaps in effective follow-up for high-risk patients with learning disabilities who disengage, and a lack of clear escalation processes. A missing structured medication review in care plans also limited staff awareness of compliance and referral routes.
Addressed to: Adult and Community Services Suffolk County Council; Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryA chest X-ray was reported as normal without the radiographer being aware of the differential diagnosis of aortic dissection. The coroner noted that more detailed clinical information provided to radiographers would assist reviews.
Addressed to: College and Society of Radiographers; General Medical Council; Royal College Emergency Medicine
AI-generated concerns summaryThe coroner noted that the non-mandatory nature of tutorials and homework in the School of Mathematics made it difficult to identify struggling students until examination failures. There was a lack of mandatory tutor contact, especially after exam failures and in the second year, meaning students could go without face-to-face interaction …
Addressed to: Bristol University
AI-generated concerns summaryThe inquest revealed Normanton Village View Nursing Home lacked formal policies regarding resident observation, food storage, kitchen security, and the care of residents with dementia or those on liquid diets.
Addressed to: Care Quality Commission; Normanton Village View Nursing Home; Rushcliffe Care
AI-generated concerns summaryThe coroner noted insufficient independent data on Taser lethality, particularly concerning the incremental risk of multiple or sustained activations, raising concerns that police training may be deficient or incomplete.
Addressed to: College of Policing; Home Office
AI-generated concerns summaryConcerns included inadequate documentation of resident observations and care plans, insufficient information and risk assessment for an aggressive resident, and a failure to conduct neuro observations despite clear head injury signs.
Addressed to: Oak Court House, Wolverhampton City Council
AI-generated concerns summaryThe coroner identified no mandatory requirement for operators of inflatable devices to register under recognised safety schemes, meaning defects may not be categorised or publicly recorded. There is also no requirement to inform enforcing authorities when equipment is deemed unsafe.
Addressed to: British Standards Institution
AI-generated concerns summaryThe coroner raised concerns that Do Not Resuscitate orders, intended for natural deaths, are being applied by paramedics in cases of overdose or self-harm, which should not be considered a natural death. This places frontline paramedics in a difficult position without appropriate intervention guidance.
Addressed to: South Western Ambulance Trust; CQC National Customer Service Centre; The Association of Ambulance Chief Executives
AI-generated concerns summaryThe coroner noted a lack of clear guidance on speed bar line specifications, insufficient inclusion of speed bar inspection in pre-flight checks, and a need for advice on configuring speed bar systems for varying pilot sizes and weights.
Addressed to: British Hang Gliding and Paragliding Association Ltd
AI-generated concerns summaryThe coroner identified a lack of physical boundaries at platform ends to prevent track access, insufficient warning signs regarding the immediate death risk from the live rail, and no national curriculum requirement to teach pupils about these dangers.
Addressed to: Department for Education; Network Rail; South Western Railway
AI-generated concerns summaryPolice training for mental health does not cover behaviours linked to common conditions. There is also insufficient understanding between police and ambulance dispatchers regarding each other's triaging processes and response times.
Addressed to: South East Ambulance Service; Surrey Constabulary
AI-generated concerns summaryThe coroner identified an inadequate audit process for monitoring non-suspicious samples and a limited protocol for managing anticoagulation regimes in community patients with identifiable risk factors.
Addressed to: Black Country Hospital Trusts; Black Country Pathological Service; Walsall Manor Hospital
AI-generated concerns summaryThe coroner noted that HGV training lacks a mandate for covering specific subjects like the use of Class VI (cyclops) mirrors, and some operators do not require drivers to undertake Safe Urban Driving or Vulnerable Road User Awareness Courses.
Addressed to: Driver and Vehicle Standards Agency
AI-generated concerns summaryNo specific concerns related to future deaths were detailed in the provided text.
Addressed to: Brighton and Hove City Council; Brighton and Hove Clinical Commissioning Group