Browse 6,458 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 summaryNo clear evidence that risks of fatal harm have been mitigated, and recommended track detection technology has not been implemented at Stratford station. There is also a lack of data demonstrating improved performance from train operator and station staff emergency training.
Addressed to: Department for Transport; Mayor of London; Transport for London
AI-generated concerns summaryThe coroner raises concerns regarding the complete absence of regulation for Non-Therapeutic Male Circumcisions, noting no requirements for practitioner training, registration, consent, infection control, record keeping, or aftercare.
Addressed to: Department for Health and Social Care, Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner raises concerns about the absence of mandatory reversing cameras for LGVs and the lack of a mandatory requirement to ensure these cameras are maintained in a fully functioning state.
Addressed to: Driver and Vehicle Standards Agency
AI-generated concerns summaryThe patient's care plan was not transported to the hospital, and a delay in electronic patient record upload meant vital choking risk information was not immediately accessible to staff. Concerns were also raised that choking risk is not routinely checked during handovers.
Addressed to: York Hospital; YAS Legal
AI-generated concerns summaryThe coroner identified a lack of protocol for patients receiving both private and NHS psychiatric care, leading to potential confusion over medication management and risks to patient safety due to uncommunicated treatment changes.
Addressed to: Northamptonshire Healthcare Foundation Trust; Northamptonshire Integrated Care Board
AI-generated concerns summaryThe coroner identified an absence of clear multi-disciplinary protocols for CT scan requests at Tameside General Hospital, noting that escalation lines were not understood at ward-level. Concerns were also raised about the incomplete record-keeping of decision-making processes for these requests.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe care home did not follow policies for pressure sore prevention and management, leading to insufficient repositioning, skin monitoring, and record-keeping for a high-risk patient. The coroner notes that the provider's improvement plan is ongoing and not yet audited.
Addressed to: Care Quality Commission, Barchester Health Care Limited
AI-generated concerns summaryThe coroner raised concerns that antipsychotic medication was abruptly stopped and the daily monitoring plan was not followed, creating a risk of relapse and mental health deterioration.
Addressed to: Sheffield Health Partnership, University NHS Foundation Trust
AI-generated concerns summaryHMP Hewell lacks "Safer Cells" within the main prison, meaning vulnerable new prisoners cannot access this important measure for reducing the risk of self-harm or suicide.
Addressed to: HM Prison and Probation Service; Probation and Reducing Offending, Ministry of
AI-generated concerns summaryThe coroner raises concerns about the lack of on-call oncology support on weekends and out-of-hours for discharge planning, and poor record management in the emergency department, which affected staff's ability to access patient information.
Addressed to: West Suffolk Hospital, Suffolk and North East Essex Integrated Care Board
AI-generated concerns summaryConcerns included preventing concurrent paracetamol prescriptions due to electronic system limitations and risks during a system change. There was also a lack of robust processes for managing therapeutic excess and insufficient guidance for assessing patient confusion.
Addressed to: Royal Pharmaceutical Society (RPS); Lewisham and Greenwich NHS Trust; Medicine and Healthcare Product Regulatory Agency; NHS England; Oracle and Cerner; Royal College of Physicians
AI-generated concerns summaryMs Silcock was discharged by the gastroenterology team without a cardiology consultation or follow-up plan, due to a lack of communication between the treating teams. Additionally, no internal investigation was conducted by the Trust regarding these issues.
Addressed to: NHS England; Shrewsbury and Telford NHS Hospital Trust
AI-generated concerns summaryThe coroner identified a communication gap between specialist doctors and the GP regarding a child's prophylactic penicillin, and noted that three GPs were unaware of the child's Sickle Cell diagnosis due to inadequate review of clinical records and the mother not informing them.
Addressed to: Barts Health NHS Trust; Department of Health and Social Care; East London Cooperatives Ltd; Maylands Healthcare Surgery
AI-generated concerns summaryInsufficient staffing and resources in A&E departments create patient safety risks, necessitating reliance on families for supervision and causing work-related stress that could worsen staff shortages.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe trust's Sepsis Screening Tool (SST) was not deployed in the patient's assessment. Work was ongoing to ensure consistent application of the SST between the Paediatric Emergency Department and paediatric in-patient units.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted repeated underestimation of a frail resident's falls risk due to incorrect assessments of likelihood and impact. Concerns were raised regarding the effectiveness and consistent application of falls risk assessment training, and that falls policy referrals were rarely actioned.
Addressed to: Westwood Hall Nursing Home
AI-generated concerns summaryThe coroner expressed concern that crucial evidence for determining the cause of a domestic explosion was not preserved, due to a lack of understanding by police and the absence of a protocol between police and the HSE on evidence security during search and rescue operations.
Addressed to: HSE; South Wales Police
AI-generated concerns summaryThe coroner noted staff uncertainty and confusion in medication dispensing and administration, leading to unclear records and a risk of incorrect dosing. Concerns also included inadequate checks of patient possessions and inconsistent use of electronic medication systems.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that urine sample bottles used by the district nursing team were not stamped with expiry dates, leading to the use of out-of-date bottles and delays in sample processing, which could contribute to future deaths.
Addressed to: Internation Scientific Supplies Ltd
AI-generated concerns summaryThe coroner noted a lack of consistent approach to pre-operative management and iron administration for chronically anaemic patients. Concerns were raised regarding the absence of clinical guidelines, processes to support them, and funding agreements between Health Boards to prevent surgical delays.
Addressed to: Aneurin Bevan University Health Board