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 local authority's reactive system for bus shelter maintenance relies on third-party complaints and lacks a proactive inspection process. The coroner suggests implementing a more proactive system, such as regular inspections, could prevent future deaths.
Addressed to: Lancashire County Council; The Chief Coroner
AI-generated concerns summaryA patient's disclosure of being a suicide risk was not followed up with an assessment, and senior clinical staff were not directly informed. The documentation of this disclosure in medical records was also delayed, making the information unavailable to other staff in a timely manner.
Addressed to: Royal Devon and Exeter NHS Trust
AI-generated concerns summaryThe coroner noted delays in the completion and trial of a new policy for transferring oxygen-dependent patients, which was not finalised by the agreed deadline following the inquest.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner noted a lack of instructions for signallers on extracting information from users and questioned whether sufficient consideration had been given to closing the railway crossing.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted potential insufficient awareness among clinicians regarding the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy, taking Warfarin, or with impaired lung/heart function. There is also a concern that clinicians may not know that maintaining INR within target range does not fully …
Addressed to: Blackpool Teaching Hospital; Glenroyd Medical Practice
AI-generated concerns summaryThe coroner identified insufficient staffing and high workload within the Metropolitan Police Service's persons' unit, which contributed to an incorrect closure of a person investigation before a welfare check was completed. This raises concerns about resource allocation and the recognition of the unit's life-saving function.
Addressed to: Metropolitan Police
AI-generated concerns summaryInsufficient specific guidance for pathologists and coroners regarding post-mortem examinations in firearms deaths, particularly for children, risks inadequate investigations and undetected homicides when suicide is assumed.
Addressed to: Chief Coroner of England and Wales; President of the Royal College of Pathologists
AI-generated concerns summaryThe coroner identified that daily mental health team involvement, a formal mental health act assessment, and engagement with the next of kin were not pursued, which could have prevented the death.
Addressed to: Norfolk and Suffolk NHS Trust
AI-generated concerns summaryConcerns included the care home's failure to implement a GP-advised observation regime and to conduct a risk assessment before returning a call bell. There was also a lack of an interpreter for mental health assessment due to funding confusion, and staff lacked training.
Addressed to: Bondcare, Clarendon Care Home; Care Quality Commission; Croydon County Council; Thornton Heath Medical Practice
AI-generated concerns summaryConcerns included inadequate information sharing about prisoners becoming detainees between HMPPS, the Home Office, and IRCs. Issues were also raised regarding SystmOne's operation at IRCs, specifically its technology, nurse access to records, and staff training.
Addressed to: HM Prison & Probation Service; Home Office; NHS England
AI-generated concerns summaryConcerns were raised regarding inadequate support and communication during the consent process for a vulnerable patient in the radiography suite, coupled with insufficient sharing of her specific vulnerabilities. The physical setup of the suite also impeded effective patient monitoring during the scan.
Addressed to: Ashford and St Peter’s Hospitals NHS Trust
AI-generated concerns summaryThe coroner sought confirmation that the Hospital Trust had fulfilled recommendations from its Root Cause Analysis following Mr Neaves's death.
Addressed to: Derriford Hospital Trust
AI-generated concerns summaryThe coroner noted the absence of a formal process for primary care practices to manage patients prescribed medication requiring regular monitoring, particularly when patients do not attend reviews.
Addressed to: Hampshire and Isle of Wight Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified a lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding regular QTc recording, which is particularly crucial for those prescribed high doses.
Addressed to: Hampshire and Isle of Wight Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns about the high injury collision rate at a specific junction, noting the need for improved signage, traffic light heads, and the layout and line of sight on its approach.
Addressed to: Slough Borough Council
AI-generated concerns summaryThe coroner noted that a door closing mechanism, identified as a ligature point in Mr Goodman's room, was not changed, and the same mechanisms remain in use in other properties managed by One Support.
Addressed to: One Hosing Group
AI-generated concerns summaryThe Welsh Ambulance Service Trust re-categorised chest pains from a Red to an Amber 1 response, extending response times from 8 minutes to up to 4 hours. This policy change, differing from England, is noted as risking patients' lives.
Addressed to: Welsh Ambulance Trust
AI-generated concerns summaryThe coroner raised concerns regarding the sufficiency of falls prevention measures and staff understanding of post-fall protocols on the surgical ward, particularly the need for medication review. Concerns were also noted about the adequacy of safety information handover between wards during patient transfers.
Addressed to: Gloucestershire Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns that the nutritional status of patients, especially when nil by mouth, was not consistently communicated effectively to staff during hospital admissions.
Addressed to: Gloucestershire Hospitals NHS Trust
AI-generated concerns summaryMultiple equipment failures, including CT scanners and computer systems, affected treatment and caused delays. Additionally, there was insufficient specialist expertise in Cushing's disease, leading to delays in seeking advice from specialist centres.
Addressed to: Pennine Acute Hospitals NHS Trust