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 identified issues with relying solely on verbal communication for recording medical conditions, suggesting a questionnaire for added accuracy. There were also concerns about the lack of an auditing process for the accuracy of nurse records.
Addressed to: Masta Limited
AI-generated concerns summaryThe coroner noted that vulnerable residents were left unsupervised in communal areas, with no clear policy for monitoring. Concerns were also raised about an unclear falls risk assessment tool and a lack of investigation into a resident's multiple falls.
Addressed to: HC-One
AI-generated concerns summaryThe coroner identified the absence of a national registry for biliary stents, posing a risk of forgotten stents. Additionally, national guidelines lack an operational definition of 'short-term' use for these stents, creating ambiguity about safe timeframes.
Addressed to: British Society of Gastroenterology; Department of Health and Social Care
AI-generated concerns summaryOngoing issues with ambulance delays, admission to emergency departments, resource availability, and patient flow persist despite previous reports. The coroner notes a lack of clear progress in addressing these recurring problems as another winter approaches.
Addressed to: Betsi Cadwaladr University Health Board; Welsh Ambulance Services
AI-generated concerns summaryThe coroner noted concerns regarding the positioning of a trespass mat, the absence of gates at the south end of platforms 1 and 2, and the inadequacy of fencing along with the low placement of a trespass deterrence mat on a ramp.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted concerns regarding a road layout that prevents westbound motorists from returning to their correct lane after overtaking, and that sat nav directions encourage them to enter the eastbound lane.
Addressed to: North & Mid Wales Trunk Road Agency
AI-generated concerns summaryThe coroner noted that only post and wire fencing was present at the railway boundary in an area frequently used by walkers, raising concerns about its adequacy.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified that meconium presence should be classified without grading, leading to specific equipment use, and that all birthing centre patients require obstetric review. There should be greater obstetric involvement and multidisciplinary team collaboration in the management of low-risk cases.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe report identifies a lack of appropriate psychological support for Mr Carton's emotionally unstable personality disorder and drug dependence in his hostel and prison placements. It also notes insufficient psychological resources for prisoners with similar conditions upon release, impeding successful reintegration.
Addressed to: MOJ; National Probation Service
AI-generated concerns summaryThe coroner identified the absence of a defibrillator at the premises and noted that Derwent staff lacked first aid training, issues which reportedly still persist.
Addressed to: Derwent Students
AI-generated concerns summaryThe coroner identified a history of road traffic incidents and fatalities on the road, which periodically receives large volumes of traffic as an M1 diversion route. A lack of an illuminated 'single carriageway' warning sign was also noted.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner noted that Toxbase guidelines for paracetamol overdose do not clearly state steps for patients re-presenting within a short time of initial attendance. This leads to clinicians commonly misunderstanding their applicability, risking patients not receiving necessary treatment.
Addressed to: Toxbase
AI-generated concerns summaryThe mental health crisis team transferred patient care to another service, placing contact responsibility on the patient shortly after an attempt, without alerting the receiving service or having a system for follow-up, risking patients being lost to services.
Addressed to: Birmingham and Solihull Clinical Commissioning Group; Birmingham Women’s and Children’s NHS Trust
AI-generated concerns summaryThe report identifies inadequacies in care, risk, and crisis management plans, insufficient staff knowledge of medical records, and a lack of family involvement. Further concerns include reliance on unqualified staff, insufficient supervision, and poor multi-disciplinary working and handovers.
Addressed to: Avon and Wiltshire Mental Health NHS Trust; Care Quality Commission; NHS England; NHS Improvement
AI-generated concerns summaryThe coroner noted that road markings and cat's eyes on a sharp left-hand bend were significantly worn away or non-existent. This condition could impact driver positional awareness and information regarding no-overtaking restrictions, raising a concern about highway safety.
Addressed to: Wiltshire Council
AI-generated concerns summaryThe coroner noted an absence of documented observations and an updated pain score before discharge. Concerns were raised regarding a lack of formal guidance for clinicians on prescribing oramorph to discharging patients, which led to inconsistencies in dosage and supply.
Addressed to: Cwm Taf University Health Board
AI-generated concerns summaryThe coroner identifies the lack of an identifiable facility for mentally disordered patients requiring special urgency beds in Leicestershire, a statutory requirement under the Mental Health Act 1983. This appears to be ignored, risking future similar situations.
Addressed to: East Leicestershire Clinical Commissioning Group; Heart of England NHS Foundation Trust; Minister for Health
AI-generated concerns summaryConcerns included Pennine Care Trust's process for raising welfare concerns and escalating issues, North West Ambulance Service's limited investigation and inadequate telephone triage, and inter-agency confusion over police roles in Section 136 incidents.
Addressed to: Greater Manchester Police; North West Ambulance Service; Pennine Care NHS Trust
AI-generated concerns summaryThe coroner identified gaps in GMP's recognition of safeguarding risks related to medication maladministration and insufficient liaison between police units. The report also notes the lack of a statutory definition for 'regular' medication checks in care homes and an uncorrected oversight regarding CCGs' statutory responsibilities for drugs.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted no formal qualification requirements for lift engineers and identified a gap where regulatory lift examination findings were not consistently read, acted upon, or escalated. Concerns were raised regarding the care home's system for managing lift examination reports and the lift company's processes.
Addressed to: Care Quality Commission; Department for Work and Pensions; Health and Safety Executive; Lancs & Cumbria Lifts UK Ltd; Serendipity Care Home