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 the nurses' station desk on the ward was incorrectly positioned, potentially affecting staff visibility of patients. A review of desk positioning at Queens Hospital was requested to ensure optimal visibility is maintained.
Addressed to: University Hospitals of Derby and Burton NHS Trust
AI-generated concerns summaryThe coroner notes insufficient black and white chevrons and faded "Slow" markings inadequately warn drivers of a sharp bend near Seaford College. There are also concerns the current speed limit sign does not provide sufficient warning.
Addressed to: West Sussex County Council
AI-generated concerns summaryThe thoroughness of Ms Lee's medication review was questioned, particularly for an unlicensed drug where updated specialist instructions were lacking. Additionally, there were significant delays in hospital correspondence being forwarded between two co-located GP practices.
Addressed to: Erith Health Centre, 50 Pier Rd, Erith, Kent DA8; Bexley Medical Group
AI-generated concerns summaryThe carer did not properly turn off a cooker despite instructions regarding fire risk, and removing cooker knobs was deemed an inappropriate method for ensuring appliance safety.
Addressed to: AR1 Homecare Limited
AI-generated concerns summaryThe coroner identified concerns regarding the absence of automatic flagging for severe symptoms, such as sepsis indicators, within the system's free text box. They also noted that separate time limits across multiple organisations contribute to unnecessary delays in patient pathways.
Addressed to: NHS England; NHS Pathways
AI-generated concerns summaryInsufficient training for occupational therapists on Telecare emergency equipment was identified, specifically regarding its availability, ordering process, and compatibility with home telephone systems. The coroner also noted a need for refresher training due to evolving technology.
Addressed to: Goodmayes Hospital; North East London NHS Trust
AI-generated concerns summaryThe coroner noted that a system dependent on patient self-declaration meant GPs were often unaware their patients were on opiate replacement therapy, risking the prescription of unsuitable medications.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified insufficient advanced warning signage for a junction with a history of fatal and critical incidents, noting the existing sign can be obscured. There was no known action plan from Derbyshire County Council, despite their awareness of the risk.
Addressed to: Derbyshire County Council
AI-generated concerns summaryThe coroner identified a lack of a national body to provide oversight and guidance to private landlords regarding safety regulations, particularly for older blinds without safety features, contributing to landlords' unawareness of associated risks.
Addressed to: Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner noted a lack of a process for clinicians to inform the Department of Work and Pensions about individuals at risk, especially those without capacity, who receive large sums of money that may be used for illicit substances.
Addressed to: Department for Work and Pensions
AI-generated concerns summaryThe coroner noted officers were unaware of a specific Drugs SOP requirement for in-cell observation. Broader concerns were raised regarding the effectiveness of police training dissemination and monitoring across the country.
Addressed to: College of Policing; National Police Chiefs’ Council; Thames Valley Police
AI-generated concerns summaryThe coroner noted a lack of awareness between GPs and a psychiatrist regarding medication decisions, leading to continued prescribing of a drug after it was advised to be stopped, and subsequent over-sedation.
Addressed to: Edge Hill Residential Home; Oldham Clinical Commissioning Group; Pennine Care NHS Trust; Royton & Crompton Family Practice
AI-generated concerns summaryThe coroner raised concerns regarding HC One's use of agency nurses who lack unit-specific induction, knowledge of policies, or patient care plans, especially when they are the only qualified staff or lead shifts.
Addressed to: HC-One
AI-generated concerns summaryThe coroner noted a significant lack of relevant information being shared with Ms Bailey's parents, despite her mental capacity and agreement for information sharing.
Addressed to: Midlands Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that high-profile individuals removed from government roles, especially those attracting significant media interest, may not receive appropriate support channels, irrespective of their mental vulnerabilities.
Addressed to: Welsh Government
AI-generated concerns summaryThe coroner notes the absence of a footpath on the A329 side of the Royal Berkshire Hotel and a lack of street lighting, requiring pedestrians to cross the road in the dark with reduced visibility for motorists.
Addressed to: Highways Authority
AI-generated concerns summaryThe coroner identifies a lack of a footpath on the A329 near the Royal Berkshire Hotel and insufficient street lighting, requiring pedestrians to cross the unlit road. Visibility for motorists is further affected by a tree canopy and a dip in the road surface.
Addressed to: Highways Authority
AI-generated concerns summaryThe coroner noted that the ambulance service's meal break policy led to a reduction in available vehicles during high demand, a known issue. Additionally, delays in ambulance turnaround times at Greater Manchester hospitals significantly decreased overall ambulance availability.
Addressed to: Blackpool Clinical Commissioning Group; Department of Health and Social Care; North West Ambulance Service
AI-generated concerns summaryThe coroner noted the inconsistent provision of defibrillators on trains and at stations by South Western Railway. Concerns were also raised about insufficient first aid training for train guards, drivers, and control staff, which may affect their ability to identify life-threatening conditions.
Addressed to: South Western Railways; British Heart Foundation; Office of Rail and Road
AI-generated concerns summaryThe Devon Partnership NHS Trust lacked an adequate mental health care facility for patients with complex needs and a policy for GP referrals, preventing formal assessment and treatment.
Addressed to: NHS England