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 noted inadequate training for support officers in recognising drug-related collapse, particularly regarding risks for recently released prisoners. Review of induction policies, staff training, and ongoing updates was recommended to improve officer awareness and resident safety.
Addressed to: Stoneham Bass
AI-generated concerns summaryThe coroner noted that different electronic record systems across mental health teams resulted in incomplete patient information for assessments. There was also poor use of available records by liaison nurses and insufficient training regarding assessments and record keeping.
Addressed to: Lancashire Care Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the absence of written unloading instructions for heavy, narrow goods (GCWUs) with complex and obscured banding. This created a risk that workers might inadvertently cut securing bands, causing the items to fall.
Addressed to: Glass and Glazing Federation
AI-generated concerns summaryThe coroner noted an incorrect weight recording, impacting anti-coagulant dosage, and a lack of clear documentation for clinical decisions. Further concerns were raised about the insufficient dissemination of lessons learned and the absence of a plan for weight estimation training.
Addressed to: Southampton General Hospital
AI-generated concerns summaryThe care management for chronic asthma lacked coordination, long-term planning, and adherence to clinical guidelines. Concerns also included insufficient communication between primary and secondary care, and a failure to refer to a tertiary respiratory service.
Addressed to: National Institute for Health and Care Excellence; NHS England; Health Education England
AI-generated concerns summaryThe coroner noted a lack of procedures to confirm district nurse referral receipt and action, and delays in implementing a standard operating procedure for safe patient discharge from acute hospitals.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted that a junior doctor applied an incorrect sling, a senior doctor did not review the patient or specify the correct sling, and the patient was discharged without a senior review or analgesia, contrary to hospital protocol.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the need to review existing pedestrian gaps in a perimeter wall to assess safety aspects for children playing in a communal grassed area.
Addressed to: Incommunities; the Local Authority
AI-generated concerns summaryThe coroner noted a lack of formal training for police officers when responding to specific circumstances and requested consideration be given to the appropriateness of such training.
Addressed to: West Yorkshire Police
AI-generated concerns summaryThe coroner raised concerns about the Registered Mental Health Nurse's (RMN) inadequate documentation, assessment of delusional symptoms, and failure to record or act on a referral regarding the deceased's mental health. There was also no Trust internal investigation into the death.
Addressed to: Lancashire Care NHS Trust
AI-generated concerns summaryThe coroner noted concerns about the handover of incident history to emergency services, identifying a risk that if the direct witness does not provide information, incorrect details may be given, potentially impacting treatment.
Addressed to: Bondcare Limited
AI-generated concerns summaryThe coroner identified a need for compulsory, assessed training on CTG tracing interpretation in all midwifery degree courses and for practicing midwives. Concerns were raised that hospital trusts should not recruit newly qualified midwives without demonstrated proficiency in this area.
Addressed to: Nursing and Midwifery Council
AI-generated concerns summaryThe coroner raised concerns about the need for a specific alcohol dependency question in custody risk assessments and noted frequent errors in custody records due to system design. There was also a lack of multi-language versions for alcohol withdrawal information leaflets provided to detainees.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner identified challenges to patient safety arising from split-site commitments and out-of-hours care. Recurring errors in patient management were noted, including poor communication, inadequate supervision, issues with early warning scores, and a failure to escalate deterioration, with insufficient progress made on addressing these issues.
Addressed to: Department of Health; Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted Millbrook's inaccurate assumption that healthcare professionals assess and report potential hazards at service-users' homes. There is no policy preventing delivery drivers from entering a property before making direct contact with the homeowner, unlike industry practice.
Addressed to: Millbrook Healthcare Limited
AI-generated concerns summaryThe report noted a delay in ambulance arrival after a person was found collapsed at home, though it was determined an earlier arrival would likely not have changed the outcome.
Addressed to: West Yorkshire Ambulance Service NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner highlighted an incongruity in the 'traffic light' classification of ligature points in psychiatric facilities, where ligatures one metre or less are 'amber' despite posing an extreme risk. It was suggested all such points should be classified as 'red' for urgent elimination.
Addressed to: NHS Improvement
AI-generated concerns summaryThe coroner raised concerns regarding the clarity and provision of outreach services by adult social care and addiction services for vulnerable individuals on a campsite. Questions were noted about available housing options and statutory duties to house these individuals.
Addressed to: Northampton Borough Council; Northampton County Council
AI-generated concerns summaryThe coroner raised concerns regarding obstructed views for oncoming traffic due to a road sign and trees at a bend, and the lack of a sufficiently wide central reservation at the location, impacting road safety.
Addressed to: Phuket Highway District
AI-generated concerns summaryThe coroner noted that details of the 'cause for concern line' should be made available to all visitors and family members to enable easy reporting of issues to the prison.
Addressed to: National Offender Management Service; Prison and Probation Ombudsman