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 risk of foreign objects preventing full tow hitch coupling engagement, which may not be visually apparent. Concerns included the absence of national guidance for inspections and checks, and inconsistent operator practices in ensuring couplings are fully engaged and free from obstructions.
Addressed to: DVSA
AI-generated concerns summaryThe coroner noted that fire retardant overalls are not a mandatory requirement for test track drivers, which creates a potential risk of death or serious injury in the event of a crash.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner noted a lack of inter-agency meetings and communication regarding a perpetrator managed at MAPPA Level 1. There is no mandatory process for information sharing between agencies despite a known history of domestic abuse and identified trigger factors.
Addressed to: HM Prison and Probation Service; Lancashire Constabulary; MOJ
AI-generated concerns summaryThe coroner noted a lack of a joint multi-agency care plan and insufficient assertive follow-up, with inconsistent care coordination for a patient with a history of disengagement. Concerns were also raised about reduced engagement and monitoring after a mental health tribunal decision.
Addressed to: Walsall Mental Health Partnership; Walsall Metropolitan Borough Council
AI-generated concerns summaryConcerns were raised regarding the use of unsuitable mattresses, inadequate staff training on bed rail management, and the lack of a comprehensive bed rail policy. Additionally, issues were noted with the timely completion of care plans and communication with families about significant medical events.
Addressed to: Care Inn Limited; Care Inspectorate Wales; Crosfield House Ltd; NHS Wales
AI-generated concerns summaryThe coroner noted gaps in formal risk assessment, search procedures, and officer handover during prisoner transport and initial custody. Delayed custody record initiation and conflicting guidance on positioning intoxicated individuals in cells were also identified.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner identifies a failure to effectively communicate key changes in clinical practice and updated medical guidance to healthcare professionals, noting that requiring practitioners to navigate multiple links increases the risk of information being overlooked.
Addressed to: Public Health England, Yorkshire and the Humber Region
AI-generated concerns summaryThe coroner identified issues in the management of reduced fetal movement, including unclear guidance for prolonged episodes and inadequate monitoring and review. Concerns were also raised regarding documentation and CTG observation during Induction of Labour.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; Stepping Hill Hospital; the Healthcare Safety Investigation Branch (HSIB)
AI-generated concerns summaryThe coroner raises concerns about the absence of a national agreement on A-level results release timing, which can lead to delays between students receiving electronic results and support, and a lack of communication with parents about the process.
Addressed to: Department for Education; Sixth Form Colleges Association; Universities and Colleges Admissions Service
AI-generated concerns summaryThe coroner noted a history of road traffic collisions involving vehicles and property at the junctions of Cooper Lane and Carr House Road, and the mini-roundabout at Cooper Lane and Carr House Lane. Local residents and campaigners have also expressed safety concerns about these junctions.
Addressed to: Calderdale Council Highways Department
AI-generated concerns summaryThe coroner raised concerns regarding the guidelines for Aspen collar use, the specific training for their application, and the effectiveness of communication between hospitals and suppliers concerning collar fitting and patient care.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified gaps in effective discharge planning, including communication of risk with GPs and families, and insufficient consideration of discharge medication risks. Concerns were also raised regarding the suitability of acute adult mental health beds for young adults and the information sharing practices between NHS trusts and private providers.
Addressed to: Cheshire and Wirral Partnership NHS Trust; Department for Education; Greater Manchester Mental Health NHS Trust; Health and Safety Executive; Secretary of State for Health
AI-generated concerns summaryThe coroner noted that the ambulance crew responding to the prison emergency lacked access to the SCAS radio system. Additionally, the first response did not include a fully qualified paramedic.
Addressed to: HMP Woodhill; South Central Ambulance Services
AI-generated concerns summaryThere was a lack of consideration that a pacemaker box change could be the source of undiagnosed infections, resulting in no cardiology referral. Additionally, no clear referral process existed for patients who became unwell following pacemaker surgery.
Addressed to: Darwin medical Practice; University Hospitals Birmingham NHS Trust; University Hospitals of Derby and Burton
AI-generated concerns summaryThe coroner noted the need to review and redraft self-harm and suicidal ideation criteria, and raised concerns about the lack of specific referral plans, insufficient feedback from services, and the need for broader psychiatric assessments.
Addressed to: Worcestershire Health Care and NHS Trust
AI-generated concerns summaryThe coroner noted an accessible 18-foot drop between floors with inadequate physical barriers, no safety netting or signage, and an uneven surface, posing a fall hazard to staff and the public.
Addressed to: URBN UK Ltd
AI-generated concerns summaryThe coroner raised concerns regarding the reliability of observations and recorded evidence by three staff members, noting inconsistencies in their accounts and suggesting that observations may not have been performed or that false evidence was provided.
Addressed to: NHS Professionals Ltd; Nursing and Midwifery Council
AI-generated concerns summaryThe coroner noted recommendations for an independent review of UK Search and Rescue operational capability and Her Majesty's Network Coastguard. Additionally, a thorough review of Search and Rescue information technology systems was advised to ensure network reliability.
Addressed to: Department for Transport
AI-generated concerns summaryThe station lacks a clear plan or flowchart for staff to follow when a person becomes ill, to mitigate potential injury to the individual or other station users.
Addressed to: Department for Transport; Govia Thameslink Railway; Office of Rail and Road
AI-generated concerns summaryThe coroner noted inadequate ACCT reviews at HMP Lewes and identified that not all prison staff, who act as first responders, had received first aid training, with one staff member lacking training for 16 years.
Addressed to: HMP Lewes; HM Prison and Probation Service