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 summaryArchitects designing care homes and healthcare premises rarely account for water safety in design, particularly concerning legionella prevention through pipework layout. Additionally, CQC inspectors lack training to identify legionella infection risks during their water safety inspections.
Addressed to: Care Quality Commission; Royal Institute of British Architects
AI-generated concerns summaryThe coroner raised concerns regarding inadequate steroid administration and prescription for Mr. Bradfield, a lack of staff training in steroid management, and the absence of a policy on steroid use, particularly for patients with co-morbidities.
Addressed to: University Hospitals Plymouth NHS Trust
AI-generated concerns summaryThe aqueduct parapet uprights have gaps exceeding current industry standards, posing a risk of people passing through and falling. Additionally, existing inspection procedures for upright embedment are subjective and inadequate for regular, accurate assessment of deterioration.
Addressed to: Canal and River Trust
AI-generated concerns summaryCyclizine is routinely administered to heart failure patients without individual risk assessment, and there is no system to balance its risks against clinical need. The hospital does not monitor deaths following its use or review alternative antiemetics.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner noted confusion among staff regarding a voluntary patient's leave status and the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.
Addressed to: Sussex NHS Trust
AI-generated concerns summaryConcerns were raised about the lack of a final treatment check, resulting in the patient not receiving antibiotics. The coroner also noted a misdiagnosis of an infected cat bite due to an online resource not adequately distinguishing it from cat scratch fever, and the absence of a feedback mechanism within …
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner noted that a safety barrier failed to redirect a heavy vehicle along its length, instead allowing it to return to the carriageway, contrary to its design. There is potential for similar incidents to arise again due to the road's extensive use by heavy vehicles.
Addressed to: Welsh Government
AI-generated concerns summaryDelays in accessing NHS mental health services led the individual to private therapy, resulting in a lack of joined-up care and information sharing. Concerns were also raised that private therapists have no obligation to obtain information about medication prescribing.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted inadequate provision of counselling and wellbeing services at Cardiff University, citing long waiting times and a reapplication process after four appointments. There are also concerns about inconsistent pastoral support from Personal Tutors, with limited training and varying levels of student contact.
Addressed to: Cardiff University
AI-generated concerns summaryThe coroner noted inadequate assessment and treatment of a vulnerable patient before discharge, a lack of clear responsibility for discharge decisions, and unclear communication among staff. Concerns were also raised about an inadequate electronic discharge summary and the patient leaving without prescribed antibiotics.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that drugs could easily enter the medium secure unit due to unsearched takeaway food deliveries, insufficient searching of residents returning from leave, and staff not being routinely searched or their food inspected upon entry.
Addressed to: Birmingham and Solihull Clinical Commissioning Group; Care Quality Commission
AI-generated concerns summaryThe coroner noted the sparse provision of pedestrian crossing points and inadequate street lighting on the A6120 at a location where pedestrians frequently cross the road. This restricts motorists' awareness of pedestrians, particularly in dark conditions.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner noted inadequate signage warning against swimming, particularly for non-readers and children, and a lack of physical barriers to prevent young children from entering the lake in areas frequented by families.
Addressed to: Park Holiday UK Limited
AI-generated concerns summaryThe coroner identifies inadequate ACCT documentation, absent healthcare input in reviews, and inconsistent staff communication, resulting in an incomplete understanding of the prisoner's condition at HMP Hewell. These issues have persisted despite prior assurances.
Addressed to: HMP Hewell; HM Prison Service
AI-generated concerns summaryThe report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThere was a delay in completing a falls risk assessment upon transfer to Ward 6, and no repeat assessment was undertaken despite signs of agitation. Additionally, a requested CT scan for a suspected head injury was never performed.
Addressed to: Manchester University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inadequacies in the practice's medication review system, including the recording of active problems and the correlation between medication and problem lists. Concerns were also raised regarding the identification of medication interactions and the need to audit administrative systems.
Addressed to: Care Quality Commission; Lisson Grove Health Centre
AI-generated concerns summaryA gap in urgent mental health services meant 16 and 17-year-olds experienced delayed access to CAMHS input. The report notes uncertainty regarding guaranteed funding for additional resources to address this service gap.
Addressed to: Sheffield Children’s Hospital; Sheffield Clinical Commissioning Group
AI-generated concerns summaryThe CCTV camera in the holding area at Grays Police Station did not extend into individual holding cells, meaning there was no visual record of detainees while inside them. The coroner identified a need for discrete camera coverage within cells to monitor detainees and potentially prevent future deaths.
Addressed to: Essex Police
AI-generated concerns summaryThe coroner noted that CT scan reports took 14 and 12 days respectively, exceeding the Trust's 5-day target, raising concerns that such delays could affect future patient treatment.
Addressed to: Mid Yorkshire Hospitals NHS Trust