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 emergency call handling system lacks the capacity to link repeat calls for the same patient at the same address, meaning there is no senior review or 'red flag' warning to alert attending crews to heightened concern.
Addressed to: JRCALC
AI-generated concerns summaryThe coroner noted that aircraft operating in unregulated Class G airspace are not required to carry electronic proximity warning or collision avoidance devices, relying instead on the 'See and Avoid' procedure.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner identified gaps in the ability to store sequential scan data with alerts and the lack of clinician access to patient records in joint obstetric and diabetic care. Clear policies are needed for joint decision-making and foetal scalp electrode use.
Addressed to: North Tyneside Hospital; Northumbria Health Trust
AI-generated concerns summaryThe coroner identified concerns regarding a police call handler's advice not to turn a person over and their inadequate guidance to seek ambulance service advice. The report also notes insufficient training and supervision for call handlers.
Addressed to: Wiltshire Police
AI-generated concerns summaryThe coroner noted that the property lacked a smoke alarm and the London Fire Brigade experienced difficulties accessing the premises due to parked vehicles.
Addressed to: London Borough of Camden
AI-generated concerns summaryThe coroner raised concerns regarding a Health Care Assistant's failure to provide first aid for choking, a delay in aid due to confusion over a DNA CPR order, and the care home's lack of internal investigation into the incident.
Addressed to: Care Quality Commission; Rossmere Park Care Home
AI-generated concerns summaryThe coroner noted the absence of an overarching risk management plan for the patient's care and treatment. Deficiencies were also identified in record-keeping for risk management strategies and handover records.
Addressed to: Glangwili General Hospital; Hywel Dda University Health Board
AI-generated concerns summaryThe coroner noted issues with standing water on the A424 due to overwhelmed drainage grips and the absence of warning signs for motorists about potential flooding on this stretch of road.
Addressed to: Gloucestershire County Council
AI-generated concerns summaryThe coroner noted significant standing water on a stretch of the A424 due to overwhelmed drainage features, and the absence of warning signs for motorists about potential flooding.
Addressed to: Gloucestershire County Council
AI-generated concerns summaryThe coroner noted insufficient resources prevented SBP staff from collecting a patient when Section 17 leave was revoked, despite it being their legal duty. This reliance placed an unfair burden on the patient's mother to return her to the ward.
Addressed to: Department of Health and Social Care; Guildford and Waverley Clinical Commissioning Group; North East Hampshire and Farnham Clinical Commissioning Group; Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the very poor condition of the cycle lane, where defects require cyclists to swerve, raising concerns about future risks to cyclists' lives if it remains unrepaired.
Addressed to: Gloucestershire County Council Highways Department
AI-generated concerns summaryInformation about the approximate age of moped riders (15-16) was not passed from initial CAD messages to the Police Control Centre team, despite age being considered a relevant factor for risk assessment and tactical decisions.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner identified poor surface water drainage on a specific road stretch, noting that water bypassed gullies due to road camber and obscured drains. Concerns were also raised regarding the general maintenance of the road and its verges.
Addressed to: Dorset Council Highways Department
AI-generated concerns summaryThe coroner raised concerns regarding whether consignees, consigners, and their employees have a sufficient understanding of hazards related to working at height on vehicles, and if adequate safety control measures are in place.
Addressed to: Driver Vehicle Standards Agency; Road Haulage Association
AI-generated concerns summaryThe coroner identified that a blood test, compliant with national guidelines, was not performed, which would have confirmed Endocarditis. The absence of this test and the prescribed antibiotics masked the disease, leading to a delayed diagnosis and treatment that likely altered the outcome.
Addressed to: MET; MFT
AI-generated concerns summaryThe coroner noted the absence of a leading physician to sign off reports and identified a six-month delay in reporting, which meant a curable treatment option was no longer available.
Addressed to: MFT
AI-generated concerns summaryThe coroner identified a lack of clarity between two agencies regarding responsibility for providing immediate patient assistance, causing confusion for the patient's family and practitioners. Direct liaison between frontline staff is recommended to clarify roles in crisis situations.
Addressed to: Hampshire County Council; southern Health NHS Trust
AI-generated concerns summaryThe coroner notes there is no mandatory requirement for electrical inspections in private rental properties to BS7671, and it is unclear when new legislation will come into force, leaving a risk of further deaths.
Addressed to: Department for Housing, Communities and Local Government
AI-generated concerns summaryThe coroner identified a nurse's insufficient assessment of a frail elderly resident, noting a failure to measure vital signs, escalate concerns, or refer for medical care after observing swelling and temperature differences in a leg, leading to a delayed diagnosis of a fractured femur.
Addressed to: Nursing and Midwifery Council
AI-generated concerns summaryThe interpretation of national ambulance service guidance for event staffing allowed first aiders in non-medical areas to be counted, potentially leading to actual medical staff in designated areas being significantly below recommended levels.
Addressed to: Health and Safety Executive; National Ambulance Resilience Unit