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 report describes Mrs Long's rapid deterioration and unresponsiveness in an ambulance after mobilisation, with her Glasgow Coma Score significantly dropping before intended transport to John Radcliffe Hospital.
Addressed to: Buckinghamshire Healthcare NHS Trust; South Central Ambulance Service
AI-generated concerns summaryThe club lacked a mechanism to ensure local authority recommendations were followed, and effective staircase widths were reduced by steward deployment, which current guidance does not fully address. Additionally, there was insufficient compliance with and auditing of steward conduct.
Addressed to: Department for Digital, Culture Media and Sport; Manchester United Football Club; Trafford Borough Council
AI-generated concerns summaryThe coroner identified inadequate fire detection and warning systems, a compromised protected means of escape, and outdated alternative escape route designs in the maisonette. These issues are widespread in similar properties, leaving occupants at significant risk from fire.
Addressed to: Local Government Association; London Borough of Barking & Dagenham Council; London Councils; National Fire Chiefs; National Housing Federation; National Landlords Association; MHCLG; West Midlands Fire Service
AI-generated concerns summaryThe coroner identified inadequate fire safety provisions in maisonettes, noting a lack of early fire detection, warning systems, and protected escape routes from upper floors. Many older properties have not been upgraded to current standards, posing significant risk.
Addressed to: National Fire Chiefs
AI-generated concerns summaryThe coroner noted that opiate medication prescribed to Cady Stewart's mother was not removed by the nursing team after her death. The medication remained in Cady Stewart's possession despite her immediate attempt to take her life following her mother's passing.
Addressed to: Tameside Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified issues with the initial emergency call categorisation, the lack of escalation or welfare check when contact failed, and a nearby rapid response vehicle being unavailable due to it being ring-fenced.
Addressed to: Aneurin Bevan University Health Board; Welsh Ambulance Services
AI-generated concerns summaryThe coroner noted a lack of medical review and nursing observations, and that signs of a bowel obstruction were not recognised. Inconsistent early warning scores (EWS) documentation across departments also meant proper escalation of treatment did not occur.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner noted poor visibility at the collision site due to a street lamp obscured by foliage, a faded "SLOW" road marking, and a speed cushion that can be straddled by vehicles and is breaking up.
Addressed to: London Borough of Lewisham
AI-generated concerns summaryThe coroner noted a lack of assessment for the suitability and volume of PEG feeding for an end-of-life patient, with no community MDT meeting held. There was also a lack of clarity between the SALT team and care home about decision-making for PEG feeding.
Addressed to: Care Quality Commission; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of clear national-level work to provide wide-ranging, proactive advice on protective security measures for urban roadways and public areas at risk of terrorist attack.
Addressed to: Department for Transport; Home Office; Metropolitan Police; Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster; British Vehicle Rental and Leasing Association; London Ambulance Service; Maritime and Coastguard Agency; Transport for London
AI-generated concerns summaryThe coroner noted that lone working arrangements delayed emergency response and CPR, exacerbated by incorrectly labelled keys. Unqualified support workers conducted suicide risk assessments without adequate guidance or training.
Addressed to: Birmingham Clinical Commissioning Group; Future Care & Social Care Association; NHS England
AI-generated concerns summaryThe coroner raised concerns that the Home Treatment Team could not revisit a patient in imminent danger due to high demand, exacerbated by inpatient bed capacity issues that divert more patients to HTT management.
Addressed to: Birmingham Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner noted Mr. Jackson was not seen by mental health clinicians despite an urgent GP request. This case, along with others, highlights concerns that under-funding of mental health services by two trusts risks future deaths.
Addressed to: Birmingham Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner noted that senior staff did not insist on a nurse moving wards despite a patient's fixation, which later contributed to an incident. Additionally, there was an unacceptable four-month delay in conducting witness interviews for a subsequent disciplinary hearing.
Addressed to: Camden & Islington NHS Trust
AI-generated concerns summaryThe coroner noted significant delays in defibrillator deployment and ambulance personnel reaching the pitch, and insufficient evidence of staff training on emergency procedures and medical emergency risk assessments.
Addressed to: Football Association; Goals Soccer Centres PLC
AI-generated concerns summaryThe hospital does not have out-of-hours reporting arrangements for x-rays, though similar provisions exist for CT and MRI scans.
Addressed to: Homerton Healthcare NHS Foundation Trust
AI-generated concerns summaryMr. Wheeler was not reviewed by a psychiatrist despite family concerns regarding his paranoia, leading to no diagnosis or treatment plan. The report also highlights a lack of inpatient mental health beds and excessive demand on Home Treatment Teams, potentially linked to underfunding.
Addressed to: Birmingham Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner identified a need for a GP to review knowledge of venous thromboembolism signs and symptoms and record-keeping practices, and for the practice to improve its system for investigating unexpected deaths. Concerns were also raised regarding the hospital trust's level of medical registrar cover at night.
Addressed to: Royal Berkshire Hospital; Waterfield Practice
AI-generated concerns summaryInsufficient staff training was identified regarding Mental Health Act Section 5(4) powers for informal patients and the duty to safeguard vulnerable crime victims by reporting incidents to police.
Addressed to: Southern Health NHS Trust
AI-generated concerns summaryThe coroner identified a lack of telephones and Network Rail contact information at the crossing, noting the possibility of repeat incidents at or near this location.
Addressed to: Network Rail