Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted a misinterpretation of a glucose tolerance test and a lack of referral to consultant obstetric care despite indicators of a large baby. This resulted in insufficient delivery planning and an inadequate review of the mother's history upon presentation for labour.
Addressed to: Gateshead Health NHS Trust
AI-generated concerns summaryThe coroner identified a lack of road markings at junctions in the Poundbury estate to indicate right of way. Parking on Lower Blakemere Road also reduced driver sightlines when approaching junctions, increasing the risk of collision.
Addressed to: Duchy of Cornwall
AI-generated concerns summaryThe coroner raised concerns about the adequacy of custody officers' training in interpreting detainees' behaviour and formulating suitable care plans, noting the detainee was released without seeing a Health Care Practitioner despite identified vulnerabilities.
Addressed to: Bedfordshire Police
AI-generated concerns summaryThe coroner noted a lack of appropriate training for mental health clinicians regarding Community Mental Health Treatment Orders, leading to insufficient appreciation of non-compliance risks and the importance of housing in discharge planning.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that checks for dangerous items in patient rooms were incomplete and flawed, citing an instance where a dressing gown cord was left available after other items were removed. This highlights an unsatisfactory system for room checks or insufficient staff training.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a single clinician and proper care plan, with medical history not obtained. Opportunities to diagnose cancer were missed due to cancelled appointments, lack of family involvement, and fragmented healthcare across three organisations with separate databases.
Addressed to: Department of Health and Social Care; MOJ; NHS England
AI-generated concerns summaryThe coroner noted fragmented healthcare responsibility in the prison, with insufficient communication and separate IT systems between providers. This affected the monitoring of the deceased's medical conditions and the establishment of clear protocols for emergency response.
Addressed to: Department of Health and Social Care; HM Prisons and Probation Service; NHS England
AI-generated concerns summaryThe coroner noted an over-reliance on offender self-reporting and significant breakdowns in information sharing between police and probation services. This included a cessation of active monitoring for some high-risk categories and insufficient meaningful engagement with offenders.
Addressed to: National Probation Service; The Chief Constable of Northumbria Police
AI-generated concerns summaryThe coroner raised concerns regarding the lack of pedestrian guard railing and impaired visibility for drivers at a busy junction. It was also noted that pedestrians frequently do not use the staggered two-stage crossings as intended, contributing to a high number of pedestrian collisions.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner noted the absence of a national programme for streptococcal infection screening in labouring women and suggested consideration of a national policy similar to Kingston Hospital's guidance on pyrexia and suspected chorioamnionitis.
Addressed to: Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner identified gaps in how information about a heightened risk of self-harm for incoming prisoners is received and shared by both prison and healthcare staff due to system limitations and inconsistent practices.
Addressed to: Healthcare Care UK; HM Prison and Probation Service
AI-generated concerns summaryThe coroner notes a gap in the partnership agreement between police and mental health services, which inadequately addresses situations where individuals in a private place experience a mental health crisis requiring an urgent multi-agency response, given limited police powers.
Addressed to: Thames Valley Police
AI-generated concerns summaryThe coroner noted the lack of an alarm or warning system on a medical air mattress and turning device, which meant there was no alert when the power cable dislodged, causing deflation.
Addressed to: Cornwall Council; Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryStaff lacked sufficient training in first aid, assisting choking residents, and preparing special dietary foods. There was also inadequate management oversight regarding staff deployment for residents at risk of choking.
Addressed to: Coed Duon Care Home
AI-generated concerns summaryConcerns were raised about the adequacy of the CAMHS GP referral form, as insufficient detail provided by a GP led to a referral being declined and delayed care. The coroner suggests the Trust reconsiders improving the form to reduce the risk of insufficient information.
Addressed to: Sheffield Children’s NHS Trust
AI-generated concerns summaryThe coroner noted delays in ambulance arrival and treatment at the hospital due to communication failures regarding a pre-arranged bed. Concerns were also raised about the call handler's failure to escalate the patient's worsening condition and the absence of a neurological algorithm in the triage system.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryThe coroner noted a lack of written policies defining the role of Welfare Officers and their training. Concerns also included improving communication channels regarding officer welfare and establishing a policy for the location of a serving officer's arrest.
Addressed to: Surrey Police
AI-generated concerns summaryThe coroner noted that road inspections are conducted at speed, which resulted in a problem with a drain on the A5 not being identified.
Addressed to: Highways England
AI-generated concerns summaryThe Trust did not correctly monitor blood sugar and ketone levels, failed to administer the correct insulin dose, and had inadequate nursing care with a lack of escalation to the medical team.
Addressed to: Maidstone & Tonbridge Wells NHS Trust
AI-generated concerns summaryThe coroner noted the foreseeable risk of pedestrian error at the John Dobson Street crossing, which is tight and challenging for drivers, with a design offering no margin for error and linked to two similar deaths.
Addressed to: Newcastle Upon Tyne City Council