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 coroner noted inconsistent prescribing practices for TED stockings by medical staff across different hospital areas, which could lead to them not being administered and increase the risk of thromboembolic formation.
Addressed to: London North West University NHS Trust
AI-generated concerns summaryThe coroner identified gaps in district nursing protocols for escalating worsening open wounds and sharing wound information with other agencies. Concerns also included insufficient visits and over-reliance on the patient’s reluctance for hospital admission.
Addressed to: Central and North West London NHS Trust
AI-generated concerns summaryThe coroner identified a lack of direct doctor-to-doctor communication for prescribing and insufficient local mental health beds. Concerns also covered absent NHS/private psychiatric care collaboration and delayed carer's assessments.
Addressed to: Central and North West London NHS Trust; NHS England
AI-generated concerns summaryThe coroner noted that the process for certifying divers fit to dive does not require obtaining the diver's GP records, identifying a risk of health conditions being misreported or undisclosed. This absence could lead to divers being certified unfit to dive, endangering themselves and potential rescuers.
Addressed to: Health and Safety Executive; Inspector of Diving
AI-generated concerns summaryThe coroner noted that an inflatable chair malfunctioned during patient transfer, leading to manual lifting without safety straps or pain relief. Concerns also included inconsistent equipment checks, inadequate record-keeping, and delays in implementing internal investigation recommendations.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryThe coroner noted that Southampton Citywatch staff are not timely in relaying emergency situations to Hampshire Police, leading to delays in police attendance. There are also unclear protocols for licensed security staff seeking urgent police assistance.
Addressed to: Hampshire Police; Southampton City Council
AI-generated concerns summaryThe coroner raised concerns that NHS England's smoke-free hospital guidance impedes the proper staging of Section 17 leave for mental health patients who smoke, potentially increasing absconding risk. The guidance also fails to adequately consider the distinct needs and risks of mental health hospitals.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a significant delay in constructing a safety-enhancing footbridge near a level crossing, despite planning permission existing since 1991, with new plans now requiring a fresh application.
Addressed to: North Somerset Council; Persimmon Homes Severn Valley
AI-generated concerns summaryThe coroner identifies an inconsistent approach to falls prevention for wheelchair users inside the nursing home, with an inadequate reliance on staff intervention. Concerns also relate to the insufficient post-incident investigation and incomplete falls risk assessment documents.
Addressed to: Cole Valley Care Limited
AI-generated concerns summaryThe coroner identified insufficient access to psychological therapy for the deceased due to internal service structures and long waiting lists, alongside a lack of available inpatient acute beds when needed.
Addressed to: Birmingham and Solihull Mental Health NHS Trust; Birmingham Cross City Clinical Commissioning Group; Department of Health and Social Care
AI-generated concerns summaryBirmingham Prison did not review or record vital information about a prisoner's history of psychoactive substance use upon transfer. The report also highlighted that no solution had been found for five years to prevent drugs being passed through the prison's plumbing system.
Addressed to: G4S; HM Prisons and Probation; MOJ
AI-generated concerns summaryThe coroner notes the need for national guidelines concerning New Interventional Procedure programmes and the training required for their implementation.
Addressed to: Newcastle upon Tyne NHS Foundation Health Trust; Royal College of Surgeons of England
AI-generated concerns summaryThe coroner noted inadequate risk assessments by First Class Care and identified a need for staff to be aware of the importance of reporting all incidents that endanger service user safety.
Addressed to: First Class Care
AI-generated concerns summaryThe coroner identified a lack of coordinated, long-term management for the child's chronic asthma, with care focused on isolated acute events rather than the underlying condition. This included no single professional taking overall responsibility, insufficient adherence to national guidelines, and inadequate record-keeping regarding risk factors and medication.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryConcerns were raised regarding a domestic fridge unit that caused a fire due to a vapour leak when only five years old. The coroner noted the potential for similar leaks in other units of the same type, particularly older ones, as many are still in circulation.
Addressed to: Glen Dimplex Home Appliances Ltd; LEC Refrigeration; Office for Product Safety and Standards
AI-generated concerns summaryNew Road's physical characteristics allow drivers to significantly exceed the 40 mph speed limit, contributing to multiple fatal collisions, leading the coroner to suggest considering traffic calming measures.
Addressed to: Cumbria County Council (Highways Department)
AI-generated concerns summaryThe coroner raised concerns regarding Egg Nightclub's protocol which stipulates that a duty manager must be called and a second set of observations taken before an ambulance can be requested.
Addressed to: Egg London Nightclub
AI-generated concerns summaryThe Early Intervention Team lacks specialist drug and alcohol workers, despite many patients having dual diagnoses, and interaction with external providers relies on self-referral. Significant waiting times for talking therapies are also noted due to recruitment challenges.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding the non-deployment of first responders and EMAS exceeding response targets. The report also notes issues with how call regrading affects response time calculations and the adequacy of conveying resources.
Addressed to: East Midlands Ambulance Service
AI-generated concerns summaryThe coroner identified that heroin users released from custody are often unaware of their reduced drug tolerance after abstinence and the fatal risks of consuming pre-custody drug levels.
Addressed to: HMP Durham