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 a 3.45-hour ambulance delay and that the danger of the patient's actions, including toxicological indicators, was not fully appreciated. Concerns included the lack of protocols for inquiring about location or enlisting agency support.
Addressed to: Cumbria, Northumberland, Tyne & Wear NHS Trust; North East Ambulance Service NHS Trust; Northumbria Police Service
AI-generated concerns summaryThe lack of fencing or other preventative measures at a bridge known as a suicide spot raises concerns about preventing people from falling.
Addressed to: Kirklees Council
AI-generated concerns summaryThe coroner noted the collision site was a notorious accident hotspot due to a lack of traffic calming measures. Concerns were raised regarding the absence of a reduced speed limit and double white lines to prevent overtaking and inform drivers of hazards.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryThe coroner raised concerns regarding the online availability of large quantities of medication, noting a lack of systems to verify purchaser suitability or limit transaction amounts and frequency.
Addressed to: 1st For Health International; StockXS Limited; Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner raised concerns regarding the absence of screening for sickle cell trait in non-UK military selection candidates, both before and after selection processes, given the increased risk of collapse or death during military exercise for those with the trait.
Addressed to: Capita; MOD
AI-generated concerns summaryThe coroner noted that non-UK military selection candidates are not screened for sickle cell trait, which significantly increases their risk during military exercise, and recommended urgent screening for all such candidates.
Addressed to: Capita; MOD
AI-generated concerns summaryThe Trust lacked an effective process for critical risk information from first responders (paramedics and police) to be documented and made available to the mental health assessment team, leading to insufficient information for assessment.
Addressed to: Goodmayes Hospital NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding an online suicide forum that provided advice on misleading mental health professionals and perfecting methods of taking one's life.
Addressed to: Department of Digital, Culture, Media and Sport
AI-generated concerns summaryA section of the A693, a de facto pedestrian crossing point, has a 60mph speed limit and no lighting. This means drivers relying on headlamps cannot see or stop for pedestrians within the required distance at night.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted a lack of clinical input when patient appointments are cancelled, which means individual needs for urgent referrals are not assessed, posing a risk that patients in serious need may be missed.
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryThe coroner noted that letters from a clinician regarding a prisoner's medication and a prescription error were not acknowledged or answered by the prison, nor passed to the healthcare team. This raises concerns about the unsatisfactory handling of important health correspondence at HMP Hewell.
Addressed to: HMP Hewell
AI-generated concerns summaryThe coroner noted the absence of a cordless phone at Duncan Court, delaying a 999 call. Concerns were also raised regarding the London Ambulance Service's triage system, which relies on the caller being with the patient to provide accurate, real-time information.
Addressed to: Creative Support Limited
AI-generated concerns summaryThe coroner noted continuing concerns regarding the accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn. Despite some measures taken, the significant health risks posed by NPS mean they are considered a probable cause of future deaths at the prison.
Addressed to: Government Legal Department; HMP Berwyn; MOJ
AI-generated concerns summaryThe coroner noted a lack of regulatory intervention and control over BBL procedures in the UK and those facilitated abroad. Concerns were also raised that patients receive complex information too close to surgery, hindering their ability to provide informed consent.
Addressed to: Department of Health and Social Care; GMC
AI-generated concerns summaryThe coroner noted a lack of contemporaneous documentation for referrals and inaccuracies in the patient's care plan, including vital weight monitoring information. Concerns were also raised about the generally poor quality of record-keeping.
Addressed to: Care Quality Commission; Rosewood Healthcare Group; Wigan Life Centre
AI-generated concerns summaryMedical practitioners did not continue VTE preventative medication for Mrs McWilliams after discharge despite her high risk. This reflects a broader concern that the interpretation of NICE guidance may lead to high-risk community patients not receiving VTE-minimising medication.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted concerns regarding the clarity and auditing of referral pathways to children's social care, and the understanding of professionals making urgent referrals. There were also gaps in multi-agency knowledge concerning private law proceedings and features of filicide cases.
Addressed to: CAFCASS; Shropshire Council; Shropshire Safeguarding Children's Board; Shropshire Safeguarding Partnership
AI-generated concerns summaryA dashboard tray creates a blind spot, but there are no warnings on the tray itself or general advice to manufacturers and haulage firms regarding this risk in moving vehicles.
Addressed to: Department for Transport; Road Haulage Association; Scania; S & J Transport
AI-generated concerns summaryThe coroner noted that expert evidence suggested more frequent diabetes monitoring than annually for individuals with a higher baseline risk, and that physical healthcare findings were not consistently shared between primary and secondary care providers.
Addressed to: Avon and Wiltshire Mental Health NHS Trust; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner notes that agencies receiving a patient and their supportive family or friends are not routinely involved in the discharge planning process.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Trust