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 noted that a trauma call and a trauma series CT scan were not initiated following a high-speed, roll-over road traffic collision, despite injuries indicating high force. C-spine imaging was also not performed despite drug consumption and neck pain.
Addressed to: Western Sussex Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted significant challenges in ensuring safe release for high-risk offenders serving short custodial sentences with no substantial probation supervision. Concerns were raised about the clarity of risk communication to sentencing authorities and the information shared with courts by prosecution and probation services.
Addressed to: MOJ
AI-generated concerns summaryWest Sussex County Council's drain clearance risk assessments did not consider zone 1 blockages, lacked regular review, and were not updated despite increased storm severity or public reports. There were also no warning signs for regularly flooding areas.
Addressed to: West Sussex County Council
AI-generated concerns summaryThe coroner noted varying post-16 mental health services and long waiting lists for autism diagnoses impede timely support for adolescents. Concerns also identified insufficient school understanding of mental health impacts from academic acceleration on autistic children.
Addressed to: Department for Education; Department of Health and Social Care; Greater Manchester Health and Social Care Partnership; Stockport Clinical Commissioning Group
AI-generated concerns summaryA shortage of appropriate neuro-rehabilitation beds in Greater Manchester prevents early effective rehabilitation, which can increase complications and the risk of death.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership; Mayor of Greater Manchester
AI-generated concerns summaryThe coroner identified insufficient care planning and communication for a patient with disabilities, including no reasonable adjustments care plan despite her needs passport. Other concerns included poor parental accommodation and reduced safeguarding support.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a gap in GP records regarding prescribed anticonvulsant medication. Clinical staff at GP and midwifery appointments did not identify the need for urgent neurology guidance concerning medication for an epileptic mother, leading to a routine rather than high-risk consultant appointment.
Addressed to: King Street Medical Practice; Tameside Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted GPs' insufficient understanding of a medication's link to pulmonary fibrosis and their lack of awareness regarding escalation procedures for side effects. Additionally, a GP amended a secondary care prescription without consulting the prescribing physician.
Addressed to: Greater Manchester Health and Social Care Partnership; Park View Group Practice; Stockport Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns about the out-of-hours transfer of a frail patient causing delayed risk assessment. Issues included poor clinical documentation, lost IT records, and a lack of dietician referrals or fluid chart review.
Addressed to: Manchester University NHS Trust
AI-generated concerns summaryThe coroner identified that training for part-time police call handlers was too short and rushed, especially for call coding, and did not adequately emphasize preservation of life. Post-training coaching and mentoring were also deemed insufficient.
Addressed to: Metropolitan Police
AI-generated concerns summaryInadequate discharge and pre-assessment processes between two care homes meant that the patient's requirement for subcutaneous fluids was not properly managed.
Addressed to: Care Quality Commission; Dovetail Court Care Home; HC-One; Lakeview Care Home
AI-generated concerns summaryThe coroner identified that pressure mats intended to detect residents leaving beds might be bypassed, and audible alarms may not be heard by staff due to their use and operation, especially when multiple alerts are active.
Addressed to: Chilton Care Centre
AI-generated concerns summaryIncomplete staff training on falls risk was noted, alongside inconsistent categorisation of residents for falls risk despite multiple incidents. There was no policy for reassessment following further falls.
Addressed to: Emral House Nursery Home
AI-generated concerns summaryThe coroner noted a shortage of inpatient beds prevented adequate assessment and treatment for the deceased. Additionally, the home treatment team's caseload significantly exceeded its intended capacity, impacting its ability to monitor patients effectively.
Addressed to: Birmingham and Solihull Mental Health NHS Trust; NHS Birmingham and Solihull Clinical Commissioning Group
AI-generated concerns summaryInformation on the NWAS system for paramedic guidance was outdated, and there was a lack of communication between community paediatric teams and emergency services regarding DNA-CPR orders for children.
Addressed to: North west Ambulance Service; Pennine Care NHS Trust
AI-generated concerns summaryThe coroner raises concerns regarding insufficient identity checks for customers purchasing hazardous items online, noting a lack of obstacles to prevent vulnerable individuals from acquiring them. The report also questioned the industry's awareness of potential risks in internet sales.
Addressed to: Chemical Business Association; Department for Environment, Food and Rural Affairs; Health and Safety Executive
AI-generated concerns summaryNetwork Rail's fence inspection procedures were inadequate, with inspectors not fully checking areas due to obstructed views and a flawed dual-submission reporting system preventing oversight. This meant inspection failures were not identified by engineers or auditors, and the initial investigation was insufficient.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted inadequate fence inspections due to obscured views and alternative access not being used. Concerns were also raised regarding a flawed dual reporting system that prevented identification of inspection failures, and an insufficient internal investigation by Network Rail.
Addressed to: Network Rail
AI-generated concerns summaryThe document indicates that concerns were raised regarding a risk of future deaths, noting the involvement of SLaM and another Trust, without detailing specific issues.
Addressed to: Kent and Medway NHS and Social Care Trust
AI-generated concerns summaryThe current 999 call system in Hampshire creates delays and confusion for those seeking help during a mental health crisis at home, due to unclear emergency service roles and a lack of effective triage and information sharing between agencies.
Addressed to: Hampshire Constabulary; South Central Ambulance Service