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 raises concerns about Bedfordshire, Cambridgeshire and Hertfordshire Police's use of unbonded 5.56mm ammunition, which was not the type recommended by ACPO since 2005 due to identified fragmentation risks.
Addressed to: Bedfordshire Police Constabulary; Cambridgeshire police forces; Hertfordshire police forces; National Police Council
AI-generated concerns summaryThe coroner noted that sellers of high-powered, kit-built vehicles are not required to provide driving courses, and these vehicles do not undergo rigorous testing regularly after initial approval. Current legislation allows drivers with a standard licence, regardless of experience, to operate such vehicles.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a 'blind spot' in Harbour Healthcare's risk assessment for internal secure doors lacking alarms, requesting CQC review related guidance and inspection procedures. Concerns also included unclear head/neck injury CT scan guidelines.
Addressed to: Care Quality Commission; Harbour Healthcare; Stockport NHS Trust
AI-generated concerns summaryConcerns were raised regarding the long-term prescription of shorter-acting benzodiazepines instead of longer-acting ones, contrary to British Association of Psychopharmacology Guidelines. The coroner also noted the need for regular medical review for patients on extended courses of this medication to reassess suitability.
Addressed to: Devon Local Medical Centre; Devon NHS Trust; Fremington Medical Centre; NHS England; Royal College of General Practitioners
AI-generated concerns summaryThe procedure for repeat prescription requests relies on administrators to identify early requests, as the surgery's software does not automatically flag them. More safeguards are needed to ensure these requests are identified and brought to a GP's attention.
Addressed to: Moat Surgery
AI-generated concerns summaryStaff lacked adequate training to recognise emergency situations and relied on presumptions when finding an unresponsive patient in a serious condition.
Addressed to: Care Agency; Care Quality Commission
AI-generated concerns summaryThe coroner identifies a lack of local in-patient detox facilities, requiring patients to travel and experience long waiting lists. There is also a need for a more collaborative approach to dual diagnosis patients, noting that separating treatment components exacerbates distress.
Addressed to: BLANK_REDACTED_TEXT Pavilions; Brighton and Hove Clinical Commissioning Group; Pavilions; Pavilions (Surrey Borders Trust); Sussex Partnership NHS Trust
AI-generated concerns summaryThe Trust had not fully addressed the issue of connectivity, despite other issues raised in evidence having been addressed.
Addressed to: North West Boroughs Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified a lack of formal health and safety training for staff and directors, an absence of specific risk assessments for swimming pool parties, and that safety procedures were not followed. Concerns also included a general lack of staff awareness in the pool area.
Addressed to: Waveney River Centre
AI-generated concerns summaryMr Vinson, despite a falls risk assessment, was not under the close supervision expected in his hospital room. Concerns were also raised regarding the unclear implementation plans for a new Enhanced Care/Observation Standard Operating Procedure.
Addressed to: City Hospitals Sunderland NHS Trust
AI-generated concerns summaryWinchester Prison has inadequate systems for storing and retrieving telephone recordings and staff interview recordings, often providing only summary transcripts. This lack of proper retention of important electronic and documentary evidence with specific prisoner records is a recurring issue, posing a risk for future deaths.
Addressed to: Carillion; HM Prison and Probation Services; HM Prison Winchester
AI-generated concerns summaryThe coroner identified failures in the police search operation, including not finding Mr Akerele's body close to his last sighting and inadequate searches of a disused graveyard where he was later found. Concerns were also raised about the Police Search Advisor being unaware of recommendations for a more thorough search …
Addressed to: West Midlands Police
AI-generated concerns summaryThe coroner noted insufficient consultant paediatrician review for sick children moved from the Emergency Department to wards, a lack of training on sepsis 'red flags', and no face-to-face medical handover protocol. Inadequate paediatric staffing levels were also identified.
Addressed to: Bassetlaw Clinical Commissioning Group; Care Quality Commission; Doncaster and Bassetlaw Hospital NHS Trust
AI-generated concerns summaryThe army's drug-testing regime failed to detect regular illicit drug use over five years, and a serviceman was forewarned of a test, enabling him to evade it. The coroner highlights that testing must be random and unannounced to be effective.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner identified that care home staff did not follow a resident's falls risk care plan or post-fall protocols for seeking medical attention and offering pain relief. Insufficient staff awareness of policies and inadequate record-keeping were also noted.
Addressed to: Care First Class UK Limited; Care Quality Commission
AI-generated concerns summaryThe hospital's DVT protocol did not conform with NICE guidelines regarding repeat ultrasound scans. Furthermore, previous DVT investigations and treatment were not communicated to surgeons or included in a subsequent pre-operative assessment.
Addressed to: Coventry & Warwickshire NHS Trust
AI-generated concerns summaryThere was a lack of immediately available falls sensors for patients assessed at high risk of falling, resulting in patients like Mr Swift being placed on a waiting list. This limited staff awareness of unsupervised mobilisation and poses a risk to other patients.
Addressed to: York Teaching Hospital NHS Trust
AI-generated concerns summaryThe coroner identified inadequate communication between hospital, GP, and care home, including misdirection of scan results. Concerns also noted the GP surgery's poor system for reviewing prescribed medication dosage and duration.
Addressed to: Care Quality Commission; Care & Social Services Inspectorate Wales; Local Health Board; Welsh Government
AI-generated concerns summaryDespite an identified risk of the deceased smoking in bed, the care plan did not prohibit carers from assisting with this, which occurred regularly. Management also lacked effective day-to-day oversight of this activity.
Addressed to: Care Quality Commission; Welsh Government Office
AI-generated concerns summaryThe coroner noted a lack of national guidance for predicting and managing fatal graft/fistula haemorrhage. Concerns were raised that A&E doctors and paramedics do not receive specific training on this risk, potentially delaying specialist review for patients presenting with such bleeds.
Addressed to: British Renal Society; Health Education England; JRCALC; Renal Association; Vascular Access Society of Britain and Ireland