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 a high number of deaths at a specific beach in Barbados, where dangerous currents are acknowledged. Concerns were raised that FCO and tour operator advice on swimming risks is too general, failing to adequately inform holidaymakers about particular dangers at individual beaches.
Addressed to: Foreign, Commonwealth & Development Office
AI-generated concerns summaryThe coroner noted the absence of a pedestrian crossing near Handsworth Park gates on Grove Lane, where people frequently cross. A parking bay opposite the park obscures drivers' views of pedestrians, creating a risk due to the 30mph speed limit.
Addressed to: Highways Department Birmingham City Council
AI-generated concerns summaryThe coroner noted a delay in prison officers accessing a radio to call for emergency assistance, due to officers leaving the cell and difficulty communicating across noisy prison levels. Although this did not affect the outcome in this specific case, such delays could be critical in future emergencies.
Addressed to: HMP Liverpool
AI-generated concerns summaryThe coroner identified the absence of a system for regular medical monitoring of care home residents and difficulties arranging GP assessments for those unable to attend surgery. Regular GP reviews within the home were suggested to improve care.
Addressed to: Lime Tree Surgery
AI-generated concerns summaryThe coroner identified concerns about the number of unmodified Bednest cribs still in circulation, where customers may be unaware of the mandatory safety modification or view it as optional, particularly those being passed on or sold secondhand.
Addressed to: Bednest Ltd; Department for Business, Energy and Industrial Strategy
AI-generated concerns summaryThe coroner recommended a review of the care and treatment provided by the Trust, particularly on Aspen Ward, following jury findings and internal reports. The CQC should ensure identified deficiencies are addressed and safe care arrangements are in place.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Care Quality Commission
AI-generated concerns summaryThe coroner noted insufficient formal training and documentation for nursing staff on connecting portable oxygen cylinders, with no record of who received training or an audit of peer-to-peer instruction. Additionally, the existing Transfer of Patients Policy did not address this specific procedure.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner noted insufficient 1:1 supervision and care planning for unpredictable falls risk, along with neuro observations not following Trust policy, performed by an untrained HCA, and lacking qualified nurse oversight.
Addressed to: Cardiff and the Vale University Health Board; Minister for Health Welsh Assembly Government
AI-generated concerns summaryThe coroner noted consistently high levels of outstanding emergency calls and waiting times that exceeded the service's target response times, posing a risk to future deaths.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryConcerns were raised regarding the accuracy of close-range firearm use, the lack of less lethal firearms or ballistic shields, and insufficient contingency planning. The coroner also noted inconsistencies in police training curricula and the absence of national standard training.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted gaps in support for individuals with co-occurring addiction and mental health issues who disengage from referrals. Concerns also included insufficient inter-agency information sharing and no lead communication agency.
Addressed to: Change Grow Live; 2Gether NHS Foundation Trust
AI-generated concerns summaryThe coroner noted poor record-keeping and a lack of updates to customer files in home care. Concerns included no action being taken after multiple reported falls or deterioration in condition, and the absence of a mental capacity assessment.
Addressed to: Home Care Support Limited; Trafford Borough Council
AI-generated concerns summaryThe coroner noted a lack of notification to family and carers regarding new equipment delivery, preventing training and risk assessment for a high-risk patient. There were no formal protocols for informing District Nurses about new equipment or changes in patient fall risk.
Addressed to: Cornwall Partnership Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the lack of preventative measures at Hells Mouth, a known location for individuals contemplating suicide, suggesting the provision of support agency phone numbers and natural barriers at the cliff edge.
Addressed to: South West National Trust
AI-generated concerns summaryThe coroner identified a poor system for requesting and securing additional nursing cover for one-to-one patient support, leading to staff confusion and frequent unavailability of help. This raised concerns about staffing levels and staff capacity to safely care for patients.
Addressed to: ABMU Health Board; Welsh Assembly Government
AI-generated concerns summaryThe coroner identified that specific risks described by Ms Williams regarding taking her own life were not considered during general risk assessments. The Trust's investigation also does not reflect this issue, potentially missing learning opportunities.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted several issues with a road junction, including a restricted view of A682 traffic due to the layout and a solid wall, alongside limited and inaccurate signage. National speed limit signs were also visible before reaching the junction.
Addressed to: North Yorkshire County Council Highways Authority
Addressed to: Care UK; HMP Pentonville; National Offender Management Service
AI-generated concerns summaryThe coroner identified deficiencies in the emergency response, including a delay in immediately alerting police, difficulties in identifying the caller's location, and a lack of clear command, control, and coordination, noting that JESIP was not followed.
Addressed to: Maritime Coastguard Agency; NEAS Foundation Trust; Northumberland Fire and Rescue Service; Northumbria Police
AI-generated concerns summaryConcerns included incomplete patient records, an agency nurse's failure to correctly apply the NEWS scoring system or escalate patient deterioration, and the Trust's insufficient system for monitoring agency staff training and compliance.
Addressed to: MEDICSPRO; MEDWAY NHS FOUNDATION TRUST