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 prescribing regime in primary care did not identify potential addiction and drug-seeking behaviour or adequately review medications to check their continued necessity.
Addressed to: NHS South Yorkshire Integrated Care Board
AI-generated concerns summarySeveral streetlights near the collision site were reported faulty but not repaired within council timescales, significantly reducing pedestrian visibility. There may also be a more fundamental technical problem causing repeated streetlight failures.
Addressed to: Highways and Transportation, Milton Keynes Council
AI-generated concerns summaryThe coroner raised concerns that extensive mould observed in one property, and potential disrepair in other properties renovated and managed by Granddwell Estates, could pose a risk of future deaths.
Addressed to: Granddwell Estates
AI-generated concerns summaryThe coroner raised concerns regarding the Emergency Assessment Unit staff's ability to respond to cardiac arrest and medical staff's understanding of identifying prolonged QTc syndrome. There was also a noted lack of a robust process for referral and investigation of this condition.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of guidance for 999 call handlers regarding 'reasonable enquiries' for missing persons reports and confusion between these and the Right Person Right Care initiative. This impacted the appropriate police response, alongside concerns about the advice given to contact healthcare providers for information.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner noted concerns that ward staff at Frimley Park Hospital were not properly recognising malnutrition risk, utilising care planning tools, or monitoring and recording interventions. Auditing of records also did not identify these repeated issues.
Addressed to: Frimley Health NHS Foundation Trust
AI-generated concerns summaryHospital reviews into unusual cardiac deaths are not widely shared with all relevant clinicians, including rheumatology specialists, limiting the understanding of a patient's full clinical picture. There is also a need for adequate assessment of rheumatological risks, such as vasculitis, in cardiac patients with specific indicators.
Addressed to: Mid and South Essex NHS Foundation Trust
AI-generated concerns summaryPolice officers demonstrated insufficient knowledge of the Mental Capacity Act 2005 regarding the use of force and restraint. There was also a lack of awareness of restraint risks and the need for collaborative planning with ambulance staff, alongside inadequate attention to the individual during and after restraint.
Addressed to: Bedfordshire Police
AI-generated concerns summaryThe coroner noted that carers did not undertake repositioning for a bed-bound patient, lacked understanding of the need for repositioning to prevent pressure sores, and had not received training on pressure sores, skin assessment, or repositioning.
Addressed to: Inspire You Care Ltd
AI-generated concerns summaryThe coroner identifies a training gap where temporary agency staff do not receive in-house training on eliciting parental concerns about a baby's wellbeing during postnatal contacts. This impacts opportunities for neonatal assessment and escalation.
Addressed to: Crown Commercial Services; NHS England
AI-generated concerns summaryThe coroner raises concerns about the under-appreciation of formalin dangers in mortuaries, noting that formalin-preserved bodies are frequently received without routine monitoring or appropriate equipment, thereby exposing users to health risks.
Addressed to: Department of Health and Social Care; Departmet for Housing, Communities and Local Government
AI-generated concerns summaryConcerns persist regarding the quality and accuracy of patient observations, including potential falsification and inadequate 1:1 monitoring by staff. Other issues include ineffective auditing of clinical records and a lack of staff guidance if the door-locking system fails.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies a need to revise pathology practices for suspected anaphylaxis deaths, recommending specific sample collection and retention, along with early communication with the senior coroner. Police investigations of unexplained child deaths should also include seizing and retaining all relevant scene evidence.
Addressed to: Cambridgeshire Constabulary; Royal College of Pathologists
AI-generated concerns summaryThe coroner noted insufficient information sharing by Essex Police with the mental health Trust concerning an individual's expressions of suicidal thoughts and welfare. Gaps were also identified in recording critical information on police systems and in seeking clarification during risk assessments.
Addressed to: Chief Constable of Essex Police
AI-generated concerns summaryThe coroner notes the limited capacity of secure mental health units means individuals needing immediate admission and deemed dangerous are detained in prison for extended periods, where their mental health needs cannot be adequately met.
Addressed to: [REDACTED] CEO, NHS England; [REDACTED] The Secretary of State for the Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that care agencies supplying staff to care homes are unregulated, meaning their recruitment processes are not inspected. This creates a risk that unsuitable agency staff may be providing care to vulnerable people without basic checks as to experience and suitability.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that the design of some anti-locking braking systems (ABS) does not effectively respond to tyre detachment, which can reduce braking performance. There is also a lack of industry-wide testing for ABS performance following tyre detachment.
Addressed to: Department for Business and Trade; Department for Transport; Driver and Vehicle Standards Agency; Toyota Motor Corporation; Toyota Motor Europe NV/SA; Toyota PLC
AI-generated concerns summaryThe coroner highlighted a procedural difference in observing detained persons using the toilet in GeoAmey/HM Prison Service custody, where indirect observation could permit the unobserved removal of prohibited items. The jury also concluded that the subsequent Level B search possibly contributed to the death.
Addressed to: GeoAmey; HM Prison Service
AI-generated concerns summaryThe absence of dedicated Tissue Viability Nurses and a Tissue Viability Service across two community hospitals presents a serious risk of pressure ulcer deterioration for vulnerable patients. Inadequate mitigation efforts have led to an increase in pressure damage on these wards.
Addressed to: East Suffolk and North Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Mrs Dearden was allocated a Community Psychiatric Nurse and key worker but received no appointments or standard assessment before her death. This was attributed to a lack of policy or procedure governing when or how appointments and assessments should take place.
Addressed to: NHS England; North Staffordshire Combined Healthcare NHS trust