Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted concerns regarding limited driver visibility of pedestrians at a specific road junction, caused by the junction's design, the position of pedestrian crossings, and street furniture creating a 'blind spot'.
Addressed to: Bolton Council, Highways Division
AI-generated concerns summaryThe coroner identifies gaps and confusion in police training regarding the management of detained persons who place items in their mouth, specifically concerning the use of PAVA spray and inconsistent guidance on forced mouth searches across different forces.
Addressed to: College of Policing; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted inadequate care where a Community Matron assessed a patient with severe dementia for a potential fracture without taking physiological readings, and wrongly deemed her to refuse an x-ray, causing a two-week diagnostic delay.
Addressed to: Care Quality Commission; Liverpool Community Health NHS Trust
AI-generated concerns summaryThe coroner identified issues with an on-call senior doctor's arrangements for being contacted by telephone, the next on-call consultant's prompt attendance due to distance, and the incorrect fulfilment of a request for two packs.
Addressed to: Sheffield Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted significant gaps in communication and information-sharing processes between custodial, health, police, court, and prison services. This led to crucial mental health information being lost or distorted, particularly due to a lack of automatic sharing for Mental Health Act assessments between agencies.
Addressed to: DAC Beachcroft LLP; Department of Health and Social Care; Hampshire County Council; Home Office; Ministry of Justice; Virgin Health Care Limited
AI-generated concerns summaryThe coroner noted that when a bed pressure sensor was removed, a substitute floor pressure mat was not immediately considered to alert staff if the patient left their bed. Regular 15-minute checks were identified as an inadequate alternative to provide timely alerts for falls risk.
Addressed to: Lambton Care Home
AI-generated concerns summaryThe coroner noted an inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures, with an inconsistent approach in the catheter lab. There were also gaps in staff training on anxiolytics and analgesics, and insufficient action plans for patient complications.
Addressed to: Frimley Park Hospital
AI-generated concerns summaryHealthcare staff lacked training in basic emergency procedures, including 999 calls and CPR, and Health Care Assistants had insufficient foundational training for their role. The deceased's PICA behaviour was also not highlighted during care home transfer.
Addressed to: Aran Court Care Centre; Care Quality Commission; Department of Health and Social Care; Jubilee Gardens Care Centre; NHS England
AI-generated concerns summaryThe coroner noted ambiguity in the interpretation of national and local safer custody guidance regarding the conditions and process for initiating an ACCT plan when a prisoner is identified as being at risk of suicide or self-harm.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner noted that road markings on the A49 Tarporley Road, including a 'ghost' island, lane dividing lines, and right turn arrows, were significantly worn and indistinct.
Addressed to: Cheshire Council, Vale Royal Area Highway Office
AI-generated concerns summarySafeguarding systems for residents who present a risk to other residents in care homes did not prevent that risk to other residents.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe RSSB Rule Book permits stopping trains only if a person may cause damage to a train, but not when a person is in danger from a train.
Addressed to: RSSB
AI-generated concerns summaryThe coroner noted that Night Orders now include a medical emergency coding system (code red/code blue) but raised concerns about whether all staff are aware of this change.
Addressed to: HMP Portland
AI-generated concerns summaryThe jury identified that Tyrone should have been classified as a vulnerable person, not an absconding suspect, based on available police information. This classification would have prompted a second, prioritised helicopter deployment, increasing the chance of finding him.
Addressed to: National Police Air Service; West Mercia Police
AI-generated concerns summaryThe coroner identified non-compliance with national sepsis protocols, including delayed doctor review and antibiotic administration. Concerns also included inadequate monitoring and management of diabetes, as well as unreliable record-keeping and poor information sharing between hospital departments.
Addressed to: Blackpool Teaching Hospital NHS Trust
AI-generated concerns summaryThe coroner noted insufficient monitoring of repeat prescriptions, a lack of structured care plans, and ineffective follow-up for missed appointments. Concerns also included inadequate staff training in the ACCT procedure and unclear procedures for prison gatehouse staff regarding prisoner safety alerts.
Addressed to: Central and North West London NHS Trust; HMP High Down; Ministry of Justice
AI-generated concerns summaryThe coroner noted the absence of warning signage regarding swimming dangers and safety aids at Lock 62 and surrounding locks, despite a previous commitment from the Canal & River Trust to install them. This lack of signage poses a risk to children playing near the water.
Addressed to: Canal and River Trust
AI-generated concerns summaryThe coroner identified a lack of contingency planning for sole carers and inadequate documentation for sharing care plans with personal assistants. Concerns included difficulties securing urgent psychiatric appointments and no follow-up after a carer reported an unusual incident.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner noted the potential for non-clinical staff to make patient transfer decisions from ITU without sufficient documentation. Gaps in monitoring for patients discharged from high-level care and the lack of involvement of a key ward nurse in a patient safety investigation were also identified.
Addressed to: Barts Health NHS Trust; University College Hospital NHS Trust
AI-generated concerns summaryThe coroner notes the ease with which an unlicensed and fatal weight loss drug (2,4 Dinitrophenol) could be obtained online from Turkey and delivered via Royal Mail.
Addressed to: Home Office