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 summaryHMP Lewes lacked a local protocol for Naloxone use, and prison officers were neither trained in its administration nor aware of its availability, despite national guidelines for all staff. Naloxone was also not stored on prison wings.
Addressed to: HM Prison and Probation Service; NHS England; NHS Improvement
AI-generated concerns summaryThe coroner noted that the lack of lighting on a motorway section was a contributory factor to collisions, posing an ongoing risk. Concerns were raised that the conversion to a 'smart motorway' may have increased risks, and the lack of lighting risk had not been reassessed.
Addressed to: Highways England
AI-generated concerns summaryThe report identifies gaps in multi-agency information sharing and communication among healthcare providers, leading to inadequate intervention despite known risks. There was also excessive reliance on the family for Mr Spooner's safety without sufficient involvement of other agencies.
Addressed to: Rope Green Medical Centre
AI-generated concerns summaryThe coroner raised concerns about the adequacy of Mental Capacity Act training, noting misunderstandings in applying best interest decision processes, consulting with carers, and instructing Independent Mental Capacity Advocates. Clarity on advocate roles was also identified as an issue.
Addressed to: Advocacy Together; Heywood Health; Pennine Care NHS Trust; Rochdale Adult Care
AI-generated concerns summaryThe coroner identified ongoing, unacceptable delays in patient handover at emergency departments, causing ambulances to be unavailable and placing patients at risk. Despite previous reports and assurances, pressures on emergency departments persist, indicating that factors causing admission delays have not been eliminated.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryEmployers may delegate work at height safety to riggers without designing adequate fall protection systems or ensuring clipping points can hold a falling person. The industry structure limits riggers' influence over safety measures, leading to routinely encountered unsafe practices.
Addressed to: The National Rigging Advisory Council (NRAG); PLASA; Unusual Rigging Ltd
AI-generated concerns summaryThe A27 Mansbridge Road lacks safe pedestrian and cycle crossings or warnings for motorists, forcing people to cross the busy carriageway unsafely where pathways end, increasing collision risks.
Addressed to: Hampshire County Council; Southampton County Council
AI-generated concerns summaryConcerns included a lack of procedures for carers to acknowledge medication changes or care plans, insufficient systems for recording verbal medication instructions, and no electronic access to patient medication history for home care. The robustness of the subsequent investigation was also noted.
Addressed to: Carewatch
AI-generated concerns summaryThe coroner noted that a patient was under a brief intervention team for an extended period without an overarching care plan or assigned key-worker, with staff unaware these provisions were possible. Concerns were also raised regarding lengthy delays in accessing psychotherapy treatment, posing a risk of future deaths.
Addressed to: North East London Hospital Trust
AI-generated concerns summaryThe coroner noted that ACCT reviews were often conducted without healthcare staff present, and relevant information from previous ACCTs was not consistently considered when new ACCTs were opened.
Addressed to: HMP Woodhill
AI-generated concerns summaryA GP prescribing system peculiarity meant post-prescription changes inadvertently made medication unavailable, a feature unknown to many professionals. The hospital also did not act on urine test results for a discharged patient.
Addressed to: NHS Digital; Royal Hallamshire Hospital; Sheffield Clinical Commissioning Group; Upwell Street Surgery
Addressed to: Care UK; HMP Pentonville
AI-generated concerns summaryThe coroner noted that many students disclosing mental health issues did not engage with support services. There were also concerns that mental health disclosure information from UCAS applications was not disseminated to university staff, limiting its effective use.
Addressed to: Universities and Colleges Admissions Service; University of the Arts London
AI-generated concerns summaryThe A34 bypass (Melrose Way Bend) presents a danger to life due to the absence of a continuous white line at the bend, which permits unsafe overtaking.
Addressed to: Cheshire East Council; Cheshire East Highways Department
AI-generated concerns summaryThe coroner identified the A34 bypass (Melrose Way Bend) as dangerous, noting the absence of a continuous white line at the bend allows overtaking on a dark stretch of road, posing a risk to life.
Addressed to: Cheshire East Council; Cheshire East Highways Department
AI-generated concerns summaryThe A34 bypass at Melrose Way Bend presents a danger to life due to the absence of a continuous white line, which allows overtaking on a dangerous stretch of road, especially in dark conditions.
Addressed to: Cheshire East Council; Cheshire East Highways Department
AI-generated concerns summaryThe coroner identified that Mr Wells' medical information held by Worthing Homes/RedAssure was incomplete, particularly regarding his learning difficulties, leading to telecare providers having inaccurate data. Additionally, the telecare system lacked integrated responder contact details and an automatic risk flagging mechanism for medical conditions or medications.
Addressed to: NHS Digital; NHS Pathways; South East Coast Ambulance Service; Worthing Homes
AI-generated concerns summaryThe coroner identified a lack of specialised assistance and referral agencies for General Practitioners to help patients wean off addictive prescription opiates. Concerns were also raised about the sufficiency of training and education for GPs in this area of care.
Addressed to: Department of Health and Social Care; Fern House Surgery; Mid Essex Clinical Commissioning Group Trust; NHS England
AI-generated concerns summaryInsufficient staffing hindered CCTV monitoring, safety warnings were absent, and signage was unclear. Furthermore, staff lacked water rescue training and understanding of emergency procedures for guests in water.
Addressed to: Alton Towers; Drayton Manor Theme Park; Legoland; Lightwater Valley Theme Park; Merlin Entertainment Limited; Thorpe Park
AI-generated concerns summaryThe coroner noted three missed opportunities for a CT scan and a lack of a facility for overnight consultant authorisation of CT scans, which relied instead on junior doctor handover. There was also no documentation of a discrepancy between doctors' accounts of a conversation.
Addressed to: ABMU Health Board