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 summaryPlanned road safety measures, including speed reduction signs and 'slow' road markings for a dangerous bend with a history of incidents, had not been implemented by the time of the inquest.
Addressed to: Highways Department, Bat and North East Somerset
AI-generated concerns summaryThe coroner noted widespread variation in how schools perceive and manage risks associated with weapons. OFSTED is asked to consider making it mandatory for inspectors to review and report on how schools manage pupil and staff safety from violent attacks.
Addressed to: Office for Standards in Education, Children Services and Skills
AI-generated concerns summaryThe coroner noted that staff who moved Mr. Jones after a fall had not undergone first aid training, which had been discontinued by Portsmouth City Council, potentially exacerbating injuries.
Addressed to: Portsmouth City Council
AI-generated concerns summaryConcerns were raised regarding the inconsistent provision of information to parents of children with Down Syndrome about their increased infection risks, and the need to consider routine chickenpox vaccination for this group.
Addressed to: Chief Medical Officer; Committee on Vaccination and Immunisation; National Clinical Director for Children & Young People; Public Health England
AI-generated concerns summaryThe STORM report was not updated with actions taken, leading to uncertainty about completed enquiries and potential loss of evidence or duplicated work. Training may be required for staff using this tool.
Addressed to: Dyfed-Powys Police
AI-generated concerns summaryThe coroner noted that falls risk assessments were often inadequate, incomplete, or not enforced, and that interventions to prevent falls were either not recognised or not implemented. Specific concerns included poor documentation of precautions, lack of referrals, and unaddressed escalation of safety needs for an observable bed.
Addressed to: East Kent Hospitals University NHS Trust
AI-generated concerns summaryThe coroner noted multiple deaths on a hospital ward caused by falls, citing inadequate, incomplete, or unenforced falls risk assessments. Specific issues included perfunctory initial assessments, inappropriate bedrail use, and a lack of updated assessments or protective measures after a fall.
Addressed to: East Kent Hospitals University NHS Trust
AI-generated concerns summaryConcerns were raised regarding the failure of staff to record observations for a high falls risk resident, the removal of a falls mat and sensor, and the inadequate quality of handover instructions provided to agency staff.
Addressed to: Arden Court Nursing Home; Bloomcare
AI-generated concerns summaryThe coroner noted that pool safety procedures could have been approached differently, including lifeguards changing positions, having more than one lifeguard on poolside, or using a motion early warning system. The report highlights the need for constant vigilance during lifeguard duties.
Addressed to: Royal Life Saving Society UK
AI-generated concerns summaryThe coroner raised concerns regarding the sufficiency of ambulance resources in Gloucestershire, the clarity for clinicians, patients, and paramedics on appropriate hospital allocation, and the expedition of urgent emergency transfers between hospitals.
Addressed to: Gloucestershire NHS Trust; South Western Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted inadequate, incomplete, or unenforced falls risk assessments led to five patient deaths on a ward, with policies and procedures for falls prevention being insufficient, especially for vulnerable patients, and lacking adequate monitoring and enforcement.
Addressed to: East Kent Hospitals University NHS Trust
AI-generated concerns summaryThe coroner identified that GPs did not follow cancer referral guidance, and noted poor medical record keeping, communication, and inadequate processes for reviewing test results. Concerns also included a lack of continuity of care and reluctance among some doctors to perform internal examinations.
Addressed to: Stonefield Street Surgery
AI-generated concerns summaryThe coroner identified inadequate management of bullying and vulnerable prisoners at HMP Wandsworth, due to staffing, communication, and cell allocation. Deficiencies also included resuscitation training, medical supply restocking, and communication between healthcare and prison.
Addressed to: HMP Wandsworth; St George’s Hospital
AI-generated concerns summaryThe coroner raises concerns about the 'red flag system' for reporting uncollected methadone prescriptions, noting that reports were routed indirectly through GMMH instead of directly to the patient's Key Worker at Addaction, causing delays. This system did not allow for earlier reporting for diligent patients who missed a single dose.
Addressed to: Greater Manchester Mental Health NHS Trust; Hindley Health Centre Pharmacy
AI-generated concerns summaryThe coroner raises concerns about a misunderstanding among some anaesthetists regarding capnography interpretation during cardiac arrest, specifically that a flat CO2 end tidal wave indicates oesophageal intubation, an issue previously highlighted in a 2011 report.
Addressed to: NHS England; North West Anglia NHS Trust; Royal College of Anaesthetists; Difficult Airway Society
AI-generated concerns summaryMental health in-patients and those under Home Treatment Teams lack access to therapy from a qualified psychologist. Timely access to the Healthy Minds service, an alternative, is also hindered by long waiting times.
Addressed to: Bury, Rochdale & Oldham Clinical Commissioning Groups; Department of Health and Social Care; NHS England; Pennine Care NHS Trust
AI-generated concerns summaryThe South West Ambulance Service Trust did not operate staggered shifts, which meant multiple ambulances were simultaneously unavailable during meal breaks, reducing service capacity.
Addressed to: Ambulance Association; Department of Health and Social Care
AI-generated concerns summaryThe care home's Braden Score for pressure sore risk may underestimate risk by not accounting for existing lesions and causes confusion due to its inverse calculation compared to the nationally recognised Walsall score.
Addressed to: St Giles Nursing Home
AI-generated concerns summaryThe coroner raised concerns that carer rotas do not always allow for travel time, which may lead to late arrivals for time-critical visits or carers cutting short visits, resulting in clients not receiving their assessed duration of care.
Addressed to: Comfort Call Limited
AI-generated concerns summaryThe coroner identified fragmented care from out-of-hours services due to a lack of joint NHS record access. Concerns also included difficulties for patients with alcohol addiction accessing timely mental health services and insufficient awareness of their complex needs.
Addressed to: Department of Health and Social Care