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 summaryConcerns were raised regarding the piling rig machine's design, including grease nipple orientation and lack of pressure release, alongside insufficient warnings, a complex manual, and inadequate operator training regarding high-pressure grease expulsion.
Addressed to: Federation of Piling Specialists; Health and Safety Executive; Soilmec Limited
AI-generated concerns summaryThe coroner noted unacceptable delays in neuroradiology reporting at Salford Royal NHS Foundation Trust, impacting patient treatment decisions. This is attributed to a national shortage of radiologists, linked to an insufficient number of training positions.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that wearing personal flotation devices on the working decks of fishing vessels is not mandatory, and legislation to make this compulsory would reduce deaths at sea.
Addressed to: Maritime and Coastguard Agency
AI-generated concerns summaryThe coroner noted that wearing personal flotation devices on deck is not mandatory on fishing vessels, and that legislation requiring their compulsory use could reduce deaths at sea.
Addressed to: Maritime and Coastguard Agency
AI-generated concerns summaryThe coroner identified inadequate documentation of multi-disciplinary team meetings regarding attendees, decisions, and outcomes. Additionally, a significant phone call from Michaela to the service was not recorded, nor was it immediately communicated to her community mental health nurse.
Addressed to: Leeds and York Partnership NHS Foundation Trust
AI-generated concerns summaryStaff at Sutton House lacked adequate training in ventilator use and were unaware of the User Manual. Furthermore, the available manual extracts did not detail correct machine operation, fault recognition, or rectification.
Addressed to: Avon Care Home Limited
AI-generated concerns summaryThe coroner noted that foetal heart rate was not correctly monitored, with maternal heart rate recorded instead, and identified a failure to follow midwifery guidelines regarding CTG assessment and obstetric reviews for prolonged pushing or maternal tachycardia.
Addressed to: Shrewsbury and Telford NHS Trust
AI-generated concerns summaryThe coroner noted a shortage of Cardiac Intensive Unit Specialist Nurses to manage patients post-operatively.
Addressed to: Health Education England
AI-generated concerns summaryConcerns were raised regarding the system of observations, particularly at night, with staff conducting hourly checks at the same time each hour rather than randomly, and some observation charts being completed retrospectively without the checks being performed.
Addressed to: Priory Group
AI-generated concerns summaryThe coroner noted a lack of guidance for clinicians on when to recommence Warfarin for patients who have suffered a head injury, which risks patients developing bleeds or strokes.
Addressed to: N.I.C.E
AI-generated concerns summaryThe coroner identified inadequate discharge planning for an unwell, elderly diabetic patient, who was sent home late without a detailed care plan, family notification, or provisions.
Addressed to: Oxford University Hospital
AI-generated concerns summaryThe coroner noted that the resuscitation team call-out criteria in the Trust's policy are too broad, potentially delaying intervention for critically ill patients. Concerns were also raised about the unsafe method of patient transfer to and from the CT scanner, which lacked appropriate medical escort and equipment.
Addressed to: Derby Teaching Hospitals NHS Trust
AI-generated concerns summaryConcerns were raised regarding the initial failure to X-ray a hip fracture after an unwitnessed fall, and that a visible fracture on a subsequent X-ray was not reported. Further issues included an unfulfilled physiotherapy review prior to discharge.
Addressed to: East Lancashire Healthcare NHS Trust
AI-generated concerns summaryConcerns were raised regarding police and ambulance services not seeking Mr Carroll's consent to inform family or friends about his suicidal ideation and hospital admission. Consequently, no one was alerted to him being taken to or discharged from the hospital.
Addressed to: Armstrong Luty Solicitors; North Yorkshire Police; Yorkshire Ambulance Service NHS Trust
AI-generated concerns summaryPoor communication between hospitals resulted in missed opportunities for patient transfer and treatment. The coroner noted a need for better education and guidance for clinicians in outlying hospitals on making neurological referrals.
Addressed to: Dudley Group of Hospitals NHS Foundation Trust; University Hospitals Birmingham NHS Trust
AI-generated concerns summaryThere is a need for more public access defibrillators, particularly in colleges and schools, and further consideration is required regarding their placement and public education on their use.
Addressed to: British Heart Foundation; Department for Education; Department of Health and Social Care; NHS England; Public Health England; Resuscitation Council
AI-generated concerns summaryThe coroner noted the absence of a protocol or written guidance for managing head injuries, including specified frequencies and ranges for general and neurological observations.
Addressed to: West London Mental Health Trust
AI-generated concerns summaryThe coroner identified a regulatory gap where the CQC did not independently assess the suitability of a care home's Nominated Individual, who had criminal convictions, due to an interpretation of Regulation 6. This particularly affects small family-owned companies.
Addressed to: Care Quality Commission; Department of Health and Social Care; The Secretary of State for Justice
AI-generated concerns summaryThe coroner noted standing and flowing water across the westbound carriageway, which police identified as a potential contributory factor to losing vehicle control. There was a history of 18 collisions at this specific location, with water mentioned as a factor in six cases.
Addressed to: Highways England
AI-generated concerns summaryThe coroner noted an ongoing security risk due to a frequently breached "locked door" on the ward and predictable patient observations that are not aligned with best practice. Additionally, a new note-recording system lacks mandatory fields to capture essential information from carers and family upon admission.
Addressed to: Devon Partnership Trust