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 summaryThe police process for notifying the Firearms Licensing Department of prosecutions was ineffective, and the department did not check a relevant PNC record for over a year before returning a shotgun.
Addressed to: Devon & Cornwall Police
AI-generated concerns summaryThe Trust did not comply with its statutory Duty of Candour, failed to properly investigate an incident internally, and did not adhere to disclosure duties to the Coroner, leading to delayed provision of critical information.
Addressed to: University Hospitals Plymouth NHS Trust
AI-generated concerns summaryThe coroner notes a significant misunderstanding of the CSRA policy at HMP Belmarsh regarding the risk categorisation of prisoners with racist tendencies. Staff were unaware that such prisoners should be categorised as "high risk," leading to a lack of clear flagging in the electronic system.
Addressed to: HMP Belmarsh; Ministry of Justice
AI-generated concerns summaryThe coroner noted a lack of training and guidance for frontline officers on how to conduct adequate searches of premises in missing person cases. Concerns were also raised about the absence of protocols for officers to escalate safety concerns during searches.
Addressed to: Thames Valley Police
AI-generated concerns summaryThe coroner noted healthcare professionals repeatedly assumed "bottle-fed" implied "formula-fed" without confirming the contents, reflecting a lack of professional curiosity and cultural awareness. Additionally, an interpreter was not used during visits for a non-English speaking mother, contrary to guidance.
Addressed to: Cornwall Council; Cornwall Partnership NHS Foundation Trust; ICB; Royal Cornwall Hospital
AI-generated concerns summaryThe coroner requested that the Essential Guide to feeding your Baby be revised to include a warning against giving cow's milk to infants under one year old, due to the risk of preventing iron absorption and causing anaemia.
Addressed to: Education and Children’s Community Health
AI-generated concerns summaryThe coroner noted ongoing visibility obstructions from old railings at the junction and raised concerns that the national speed limit on the road does not account for the junction's dangerous nature.
Addressed to: Conwy County Borough Council; Road (Highways Safety) related deaths; Wales prevention of future deaths reports (2019 onwards)
AI-generated concerns summaryCurrent driving licensing and testing arrangements may not adequately prepare newly qualified drivers for real-world conditions like multiple passengers or rural roads. Concerns also exist about how insurers identify young drivers' true risk, including 'fronting' practices and inconsistent telematics use.
Addressed to: Association of British Insurers; Brake; Chartered Insurance Institute; Department for Transport; Driver and Vehicle Standards Agency; Financial Conduct Authority; Snap Group Limited
AI-generated concerns summaryThe coroner noted that medical equipment was not retained for forensic investigation, hindering the identification of contamination sources. Concerns were also raised regarding inconsistencies in guidance on the use of filters in parenteral feeding and the need for integrated risk management between manufacturers and health providers.
Addressed to: NHSE; NHS England; [REDACTED], Chief Executive, Medicines and Healthcare Products Regulatory Agency (MHRA), 10 South Colonnade, Canary; [REDACTED], Chief National Medical Examiner, National Medical Examiner’s Office, 6 Alie Street, London E1 8QT
AI-generated concerns summaryThe coroner noted an increase in toxicological requests for a specific substance, highlighting the need for specialist analysis to aid potential prosecution of suppliers. The report suggests the Chief Coroner consider guidance on routine toxicological analysis in poisoning investigations.
Addressed to: Secretary of State for Health and Social Care [REDACTED]; Secretary of State for the Home Department [REDACTED]
AI-generated concerns summaryThe coroner raises concerns about the absence of pre-screening for contrast medium allergies in patients who have not previously had it, and the unexplained presence of Lidocaine in the deceased's system despite a known allergy and no documented administration.
Addressed to: Medicines and Healthcare Products Regulatory Agency; Royal College of Radiologists; Department of Health and Social Care; University Hospitals of Northamptonshire NHS Group
AI-generated concerns summaryThe coroner noted confusion regarding which Integrated Care Board was responsible for commissioning a patient's care, leading to delays in securing appropriate placements and accessing necessary funding. This reactive process for determining ICB responsibility could delay essential care or changes in future cases.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified difficulties with information sharing between health services due to different IT systems and a lack of a shared understanding of what constitutes relevant information. This included important information being recorded only in the baby's notes, which meant the mother's mental health picture was incomplete.
Addressed to: Derbyshire Community Health Services NHS Foundation Trust; Derbyshire Healthcare NHS Foundation Trust; NHS Derby & Derbyshire Integrated Care Board; NHS England; Sett Valley Medical Centre
AI-generated concerns summaryThe coroner raised concerns about the complex processes and lack of streamlining in the treatment of subarachnoid haemorrhages, particularly regarding the unclear overall responsibility between neurosurgical teams and interventional radiologists, which may place patients at risk.
Addressed to: [REDACTED] President of The Royal College of Phyisicians; [REDACTED], President of The Royal College of Radiologists; [REDACTED] President of The Royal College of Surgeons
AI-generated concerns summaryThe coroner noted significant cultural tensions between midwifery and obstetric staff at Good Hope Hospital's maternity unit, which may have delayed urgent medical action. A wider hierarchical and bullying culture was identified, hindering staff contribution to decision-making and causing anxiety in urgent situations.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of oversight regarding the rental of food delivery licenses to children under 18. This practice places vulnerable children in lone working environments, increasing their risk of road traffic collisions.
Addressed to: Department for Business and Trade; Department for Education; Department for Transport; Department for Work and Pensions; Health and Safety Executive
AI-generated concerns summaryThe high availability of illicit drugs, particularly new psychoactive substances, and mobile phones at HMP High Down facilitates prisoner coercion, bullying, and violence, with staff reporting no improvement in these persistent issues.
Addressed to: HMP High Down; HMPPS; Ministry of Justice; The Minister of State for Prisons, Parole and Probation
AI-generated concerns summaryConcerns were raised regarding a nurse untrained in tracheostomy management being on a unit with patients requiring such care, and insufficient management oversight of staffing decisions. Additionally, the quality of care notes was poor, and an agency nurse lacked essential system access.
Addressed to: Acer Mews Care Home; Care Quality Commission
AI-generated concerns summaryThe coroner noted an absence of national guidance concerning the use of propofol for short-term sedation in children and young people on Paediatric Intensive Care Units.
Addressed to: National Institute for Health and Care Excellence; Paediatric Critical Care Society; National Clinical Director for Children and Young People,
AI-generated concerns summaryThe coroner raised concerns regarding the lack of available elderly care ward beds, which resulted in a complex elderly patient remaining in A&E. This environment was unsuitable for her specialist care needs, leading to delayed access to appropriate management and impacting her recovery.
Addressed to: Department of Health and Social Care; NHS England