Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted a potential public misunderstanding regarding speed limits for police emergency vehicles and raised concerns about the absence of a visual indicator in police cabs to confirm siren activation, following instances where officers mistakenly believed sirens were on.
Addressed to: National Police Chief’s Council
AI-generated concerns summaryWest Midlands Police experienced significant backlogs of overdue P2 incident logs due to insufficient officers for deployment and inadequate control room staffing. Dispatchers were overwhelmed, and escalation processes for overdue logs were ineffective.
Addressed to: West Midlands Police
AI-generated concerns summaryThe coroner raised concerns that safety adaptions removed from a window in a tenant's flat have not been replaced. There are concerns about the landlord's lack of action to ensure advised safety conditions are maintained for tenants.
Addressed to: Landlord
AI-generated concerns summaryThe coroner identified a need to clarify 'Recognition of Life Extinct' guidelines regarding the criteria for declaring death and the definition of 'similar massive injuries'. Additionally, ambulance crews lacked awareness of local fire service vehicle lifting capabilities.
Addressed to: JRCALC
AI-generated concerns summaryThe coroner noted a risk of floors failing in 254 properties and inconsistency across gas distribution networks regarding policies for inspecting adjoining properties for gas.
Addressed to: Cadent Gas Ltd; Gas Safe Network; Institution of Gas Engineers; Scotia Gas Network; Wales and West Utilities
AI-generated concerns summaryThe coroner noted that closing safeguarding referrals without prior parental contact limits social workers' ability to assess child welfare. Not sharing information about closed referrals with other agencies may prevent them from taking appropriate action, potentially undermining child protection.
Addressed to: Bury Council
AI-generated concerns summaryThe coroner noted a lack of referral to a Tissue Viability Nurse (TVN) for the deceased despite a worsening pressure sore and increased risk factors. There was no clear guidance on when TVN referrals should be made, especially for patients with additional risks.
Addressed to: Shrewburys and Telford Hospital NHS Trust
AI-generated concerns summaryThe coroner noted the design of bed rails could allow patients to fall easily. Concerns also include the definition, administration, staff breaks, and training communication of 1:1 care in hospital settings.
Addressed to: Chief Coroner of England & Wales; Nursing and Midwifery Council; St Georges University Hospital NHS Trust
AI-generated concerns summaryThe coroner noted concerns that healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process, requesting details on appropriate training and auditing.
Addressed to: HMP Dovegate
AI-generated concerns summaryThe coroner noted repeated fatal collisions at the same A690 location and suggested a review of safety road restriction systems, alongside a reassessment of drainage and surface water clearance.
Addressed to: Sunderland City Council
AI-generated concerns summaryThe coroner identifies a lack of clear police guidance on interpreting Section 136(1A) of the Mental Health Act 1983 regarding the power to detain individuals in hotel rooms. This could lead officers to mistakenly believe they lack the power to remove a person to a place of safety.
Addressed to: College of Policing; South Wales Police
AI-generated concerns summaryThe coroner noted Scammonden Bridge is a known location for fatalities and previous PFD reports have been sent to Kirklees Council and Highways England. Concerns remain that proposed steps to prevent future deaths at the location may not have been fully actioned.
Addressed to: Highways England; Kirklees Council
AI-generated concerns summaryThe coroner noted that the family was not provided with the IDDSI definition of 'bite sized' in the eating and drinking plan or a leaflet. No specific advice was given regarding bread products or eating with hands relevant to the deceased's diet.
Addressed to: Walsall Healthcare NHS Trust
AI-generated concerns summaryThe jury identified a need for Bradford District Care NHS Foundation Trust to review ligature risks from personal items. Concerns also arose about the design of doors on Oakdale ward, suggesting hinge pin covers.
Addressed to: Bradford District Care NHS Trust
AI-generated concerns summaryThe coroner noted the absence of fences at Tennyson Down cliff edge and a lack of signs providing support numbers for individuals experiencing mental distress, suggesting similar improvements to those planned for Culver Cliff.
Addressed to: Suicide Prevention Group, Isle of Wight Council; National Trust for the Isle of Wight; Public Health for the Isle of Wight
AI-generated concerns summaryThe coroner identified insufficient control and designated safe areas for pedestrians on the race track after races, alongside active stock cars and recovery vehicles. The report also describes gaps in risk assessments, prize-giving procedures, and the safety of unprotected staff on the track.
Addressed to: Incarace; ORCi
AI-generated concerns summaryPatient record systems do not ensure timely communication of urgent information to relevant staff, and vulnerable patients are obliged to share walking aids on hospital wards.
Addressed to: County Durham and Darlington NHS Trust
AI-generated concerns summaryThe coroner identified an absence of national guidance on monitoring people with refractory epilepsy, particularly concerning assistive technology. Concerns were also raised that Stockport Council did not consistently undertake annual Care Act Reviews for eligible individuals, citing insufficient resources provided to local authorities.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; Stockport Borough Council
AI-generated concerns summaryThe coroner noted an unexplained delay in calling an ambulance to transfer Ms Buckley during a medical emergency and unclear policies regarding when to mobilise a medical emergency team and call an ambulance.
Addressed to: General Council
AI-generated concerns summaryThe coroner identified that road safety on the A468 could be improved by extending double white lines to restrict overtaking, given the area is anecdotally known for motorists driving at speed.
Addressed to: Newport County Council