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 that pedestrians approaching the A61 from Owlerton Green might be misled by a green light for an adjacent crossing, potentially causing them to miss a red light prohibiting crossing the A61 northbound lanes.
Addressed to: Sheffield City Council
AI-generated concerns summaryThe coroner raises concerns about the absence of a legal requirement for quad bike drivers to wear crash helmets, even for bikes adapted for road use, noting this presents an avoidable risk of deaths.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner identified inadequate record keeping, specifically a lack of detailed documentation regarding a detained patient's risks, the rationale for granting leave, and clinical state assessments before leave. This hinders effective handover and informed decision-making.
Addressed to: Lancashire Care NHS Trust
AI-generated concerns summaryThe coroner identified failures in the appropriate management of hyponatraemia, including a lack of adherence to national guidelines for treatment and monitoring serum sodium levels. Concerns were also raised about inadequate medical planning, poor documentation, and an insufficient understanding of hyponatraemia management by some consultants.
Addressed to: Care Quality Commission; Epsom General Hospital; Royal College of Physicians
AI-generated concerns summaryThe coroner noted concerns regarding unnecessary patient transfers to and from the Princess Royal Hospital, which were carried out without supporting paperwork.
Addressed to: Brighton and Sussex University Hospital NHS Trust; NHS England; Clinical Commissioning Group; Department of Health
AI-generated concerns summaryThe coroner noted concerns regarding potential ongoing sensor system outages, which could prevent staff from being alerted to resident falls, and raised the need for steps to safeguard residents known to slide when seated in a chair.
Addressed to: Baycroft Care Homes; Senior Villages
AI-generated concerns summaryThe coroner identified a risk that patients treated as outpatients could be lost to follow-up care, noting that one patient was not followed up for eight years without explanation.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryThe coroner raised concerns about significant delays in GPs receiving critical mental health information from the Mental Health Trust due to incompatible IT systems. Additionally, the Mental Health team failed to record and follow up on a patient referral.
Addressed to: Birmingham and Solihull Mental Health Trust
AI-generated concerns summaryThe coroner notes that not all doctors were aware of the BNF mobile device APP, which is a useful tool for identifying potential drug interactions.
Addressed to: Clinical Commission Group; NHS England
AI-generated concerns summaryNursing staff lacked space and resources for patients after triage, leading to waits in corridors with no meaningful interaction or permanent medical staff. Emergency department waiting times frequently exceeded national targets, with some patients waiting up to seven hours.
Addressed to: Care Quality Commission; The Dudley Group Trust Foundation Trust
AI-generated concerns summaryThe coroner noted that a path near an accident scene lacked clear signage and lighting for pedestrians, making its usability unclear. There was also an indication that the approach to such circumstances might not change in the future.
Addressed to: AMEY
AI-generated concerns summaryThe coroner raised concerns regarding the omission of VTE prophylaxis due to EPR technical difficulties, particularly for trauma patients cared for on non-trauma wards, and that VTE prophylaxis alerts on EPR were frequently not seen by medical staff.
Addressed to: Oxford University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need for measures to protect pedestrians crossing the A63 dual carriageway in the vicinity of Waterloo Manor Hospital.
Addressed to: Leeds City Council Highways Department
AI-generated concerns summaryThe coroner noted concerns regarding carers facilitating smoking for a high-risk individual despite fire risks, a lack of staff training in home safety assessment, and fire detectors that would not alert emergency services for a disabled person.
Addressed to: Devon County Council; Guinness Care and Support
AI-generated concerns summaryThe coroner raises concerns that an outdated isolation procedure from previous work was not reviewed for new work of a different nature, leading to confusion. There was also a lack of clarity regarding responsibility for safe isolation between the contracting parties, and the Permit To Work process was completed incorrectly.
Addressed to: Carlsberg Supply Co Ltd
AI-generated concerns summaryInconsistencies were noted in the Modified Early Warning Score (MEWS) Standard Operating Procedures within Birmingham Heartlands Hospital's Emergency Department, with staff receiving conflicting instructions on escalation pathways. This poses a risk of inconsistent patient care and confusion for non-ED clinicians.
Addressed to: University Hospitals Birmingham NHS Trust
AI-generated concerns summaryThe coroner noted that the patient's high-risk surgery was scheduled for a Thursday, meaning post-operative care occurred under weekend staffing. Concerns were also raised about the patient's location on a general surgical ward and a lack of fluid balance charts during dehydration.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner identified delays in mental health assessments, a lack of welfare checks after a care package withdrawal, and misunderstandings among social workers regarding Mental Health Act referral procedures.
Addressed to: East London NHS Trust; London Borough of Hackney
AI-generated concerns summaryPolice training should incorporate how to distinguish a struggle to breathe from resistance, recognise silent choking, and assess breathing in stressful situations. Guidance is also needed for officers on managing assistance from members of the public.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted a lack of first aid training for adult volunteers and teachers, especially for choking, and the absence of a defibrillator. Concerns were also raised about insufficient oversight for maintaining current training, supervision, and child safeguarding.
Addressed to: London Borough of Lambeth; South London Islamic Centre; The Chief Coroner; The Lambeth Children Safeguarding Board