Browse 6,488 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 raised concerns regarding the limitations of the 'see and avoid' principle for aircraft collision prevention, the lack of mandatory and compatible anti-collision devices, and the absence of air traffic control at an active airfield.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner noted a lack of formal procedure for prison reception staff to routinely share self-harm and welfare alerts from the CNomis system with nurses during a prisoner's reception medical screen. This could mean significant alerts are not seen by healthcare staff.
Addressed to: HMP Wymott
AI-generated concerns summaryThe anaesthetic department commonly used non-insulin syringes for insulin administration, despite a national alert. Additionally, doctors lack mandatory training on insulin devices, and no process exists to check compliance with safety alerts.
Addressed to: Royal Free Hospital
AI-generated concerns summaryThe coroner noted GMMH's policy limited prescription supply to 28 days, leading to a patient running out of essential medication on a longer trip and potentially having to source it from an illicit market abroad.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryThere are no formal procedures for health services to report non-fatal anaphylactic reactions caused by commercial food premises to regulatory bodies like Trading Standards. This lack of communication prevents timely intervention and appropriate action regarding allergen risks at such premises.
Addressed to: Department for Health; Food Standards Agency
AI-generated concerns summaryThe coroner noted concerns about the 2:1 tree surgeon to groundsman ratio, meaning a lack of immediate support, and that the groundsman was not qualified for aerial work. Communication via shouting and hand signals was also difficult due to tree density and height.
Addressed to: Arboricultural Association; Forestry Commission; Health and Safety Executive
AI-generated concerns summaryThe coroner noted contradictory information in the discharge summary led to discontinuation of life-long medication, which clinicians later failed to identify. Additionally, recommended equipment and support were not provided to the patient after discharge.
Addressed to: Ashford and St Peter’s Hospital NHS Trust
AI-generated concerns summaryThe coroner identified significant delays and a lack of reporting on plain radiology due to a shortage of Consultant Radiologists. This meant radiological investigations, crucial for diagnosis and clinical decision-making, were not completed within required timescales or at all.
Addressed to: Department for Health; Ministerial Correspondence and Public Enquiries Unit
AI-generated concerns summaryThe coroner noted a lack of recording for verbal information shared with RAID practitioners and that Lifeline/CGL notes were not promptly entered, with some contemporaneous notes later destroyed. Concerns also included Pennine Care documentation accessibility and a GP practice's assumption that a referral had already been made.
Addressed to: Change Glow Live; Heaton Norris Health Centre; Pennine Care NHS Trust
AI-generated concerns summaryThe report identifies multiple issues with the road traffic layout, including a lack of pedestrian look markings, confusing independent green man phasing across dual junctions, and a missing signal louvre, which may particularly impact foreign visitors.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner identified inadequate formal training and written guidance for supervising officers, a lack of personal breathing guards for senior officers during resuscitation, and insufficient staff awareness of the specific manner of unnatural deaths.
Addressed to: HMP Preston; HM Probation and Prison Service; Ministry of Justice
AI-generated concerns summaryThe coroner noted delays in discharging patients who were medically fit for discharge, specifically due to difficulties in securing suitable social placements, leading to prolonged hospital stays.
Addressed to: North Midlands NHS Trust
AI-generated concerns summaryThe coroner identified a lack of clear written procedures for lone working staff regarding trespassers in non-public areas, leading to inconsistent practices. There were also concerns about difficulties and insufficient clarity for staff in accessing and using recorded CCTV.
Addressed to: London Underground
AI-generated concerns summaryThe coroner noted that Mr. Berryman's chest infection assessment was conducted in a waiting area without a physical examination or a clinical record being made.
Addressed to: Wells Road Surgery
AI-generated concerns summaryThe coroner noted insufficient information sharing from police and magistrates' court to the prison regarding the deceased's behaviour and mental state. There was also a lack of mental health assessment at court and no consideration of appropriate placement for a vulnerable prisoner.
Addressed to: HM Courts and Tribunals Service; Northamptonshire Police
AI-generated concerns summaryUnclear signage at M1 Junction 14's slip road causes driver uncertainty and traffic queuing. A suggestion was made for a run-off lane at this junction, similar to provisions on newer motorways.
Addressed to: Highways England
AI-generated concerns summaryThe coroner identified inaccurate record-keeping by a doctor, noting telephone consultations were misrepresented as in-person and a non-existent abdominal examination was recorded. A pattern of telephone diagnoses at the practice was also raised, leading to a referral to the GMC.
Addressed to: GMC Fitness to Practise Team
AI-generated concerns summaryConcerns included inadequate antenatal screening for SGA babies, a lack of guidance on interpreting fetal heart rate recovery, and insufficient CTG availability in birthing centres. The coroner also noted unclear transfer policies between maternity and ambulance services, impacting emergency response classification.
Addressed to: Department for Health; Portsmouth Hospitals NHS Trust; South Central Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted significant paramedic and EOC clinician vacancies, causing ambulance shortages and missed clinical re-assessments for delayed calls. The ambulance service also achieved only 60% of its monthly call audit target.
Addressed to: South East Ambulance Service
AI-generated concerns summaryThe coroner identified concerns regarding a dangerous informal pathway, used by pedestrians and cyclists, that poses a risk when accessing or leaving the towpath.
Addressed to: Banes Highways; Banes Park and Services; Canal Trust Bath