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 care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Addressed to: Ambassador House Care Home
AI-generated concerns summaryThe coroner noted an unactioned psychiatric referral during an inpatient stay and a subsequent unsuitable referral to Healthy Minds for complex PTSD due to insufficient detail. A commissioning gap for complex PTSD services was also identified.
Addressed to: Churchgate Surgery; Pennine Care NHS Trust; Tameside and Glossop Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Addressed to: Care UK Clinical Services; National Offender Management Service; NHS England; South Essex Partnership Trust
AI-generated concerns summaryConcerns were raised regarding the absence of a medication review process and a failure to conduct full risk assessments following incidents that indicated risk. The coroner also noted issues with multi-disciplinary review of observations and clarity within the observation policy.
Addressed to: Greater Manchester West Mental Health NHS Trust
AI-generated concerns summaryThe coroner identified that midwives and a junior obstetrician did not correctly interpret an abnormal cardiotocograph (CTG) trace. The report raises concerns about a general lack of core skills in CTG interpretation and recommends mandatory, quality-controlled training modules and competence testing for all staff.
Addressed to: Royal College of Midwives; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted a history of collisions at the A36/Branch Road junction and recommended reducing the speed limit on the A36. Concerns also included the need to review and improve road signs and carriageway markings to warn drivers of junction risks, along with repairing the high friction surface.
Addressed to: Avon and Somerset Constabulary; Highways England
AI-generated concerns summaryThe design of the Denmark Hill with Orpheus Street junction allows left turns from lane 2 to conflict with straight-ahead traffic. Issues include the lack of road surface warnings and the high volume of bus traffic.
Addressed to: London Borough of Southwark; TFL; the police
AI-generated concerns summaryThe coroner identified deficiencies in the school's service road design, where an inadequate bus bay required children to cross a busy road, and noted insufficient staff supervision during bus boarding. There was also a lack of accountability among stakeholders for ensuring site safety during the school's construction.
Addressed to: Bridgend County Borough Council; Maesteg Comprehensive School
AI-generated concerns summaryThe coroner raises concerns that reduced grip road surfaces on the Cycle Super Highway and at junctions pose a hazard for road users, particularly cyclists. An urgent review of these surfaces and their replacement with higher grip alternatives is recommended.
Addressed to: TFL
AI-generated concerns summaryThe practical implementation of Section 17 leave, particularly concerning the mandatory provision of 'Records of Grant' copies to patients and an additional party, was identified as a concern.
Addressed to: Central and North West Hospital NHS Trust; HMP Woodhill; Oxford Health NHS Trust
AI-generated concerns summaryThe coroner noted a lack of co-operative working and communication between the Early Intervention in Psychosis Service and the Substance Misuse Service, which also led to an incomplete Root Cause Analysis report.
Addressed to: Solent NHS Trust
AI-generated concerns summaryThe coroner identified that the road is unsafe for driving at 70 mph due to its narrow, unlit carriageway, absence of kerbs or pavements, and bordering hedgerows and trees.
Addressed to: Kent County Council
AI-generated concerns summaryThe coroner noted insufficient training for physical healthcare staff regarding mental health needs and the application of the Mental Health Act. Concerns were also raised about the persistent lack of available psychiatric beds, which caused delays in patient transfer.
Addressed to: Devon Partnership NHS Trust; NHS Northern, Eastern and Western Devon Clinical Commissioning Group; Royal Devon and Exeter NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient emphasis on discharge advice, specifically the lack of explicit communication to the patient and family about the critical importance of follow-up medication and the absence of a contact number for the district nursing team.
Addressed to: Whittington Hospital NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the poor state of repair of the pavement and roadway at a junction, noting the lack of a clear boundary between them. This led to pedestrians walking straight across and vehicles sometimes cutting the corner.
Addressed to: Dorset Highways Departments
AI-generated concerns summarySignificant handover delays at two district general hospitals led to an ambulance being delayed in its dispatch to the deceased. These delays exceeded the agreed 15-minute handover time and have worsened since 2016.
Addressed to: Neville Hall Hospital; Royal Gwent Hospital; Welsh Ambulance Service NHS Trust; Welsh Government
AI-generated concerns summaryThe coroner identified that adding rumble strips to the existing double white lines could reduce the risk of vehicles inadvertently straying into oncoming lanes. Concerns were also raised regarding the completion timeframe for risk assessments and remedial actions following the incident.
Addressed to: Merseyside Passenger Transport Authority
AI-generated concerns summaryThe coroner noted a lack of awareness regarding the safety-critical function of ladder spigots and how easily they can be accidentally removed, which could pose future health and safety risks.
Addressed to: Department for Business and Energy and Industrial Strategy; Health and Safety Executive; Youngman
AI-generated concerns summaryThe coroner identified matters of concern that were set out in detail during the summing up of the inquest.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner notes that overturns in this industry are under-reported, with causes not well understood due to a lack of investigations, inspections, and specific industry guidance. There is also a lack of routine inclinometer use and awareness of overturn risks on slight gradients.
Addressed to: Health and Safety Executive