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 raises concerns about fire and rescue services implementing measures to reduce risks from heat exposure and communication loss during operations. There are also concerns regarding the adequacy of procedures, training, and hazard recording for incident management, role handover, and thermal imaging camera use.
Addressed to: Chief Fire and Rescue Services; Home Office
AI-generated concerns summaryThe coroner identified a lack of national guidance for monitoring patients with pleural plaques, leading to inconsistent medical approaches and a risk of patients being lost to follow-up, potentially delaying early diagnosis and treatment.
Addressed to: Department of Health and Social Care; Royal College of Physicians
AI-generated concerns summaryThere was no system to alert passengers that the 191 bus was about to move, prompting the coroner to suggest introducing such a notification system.
Addressed to: Transport for London
AI-generated concerns summaryNo specific concerns are provided in the truncated text.
Addressed to: Lancashire Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of standardised treatment programmes for fire setters within HM Prison Service and that a suggested therapeutic community option for Steven's care was not pursued before his death.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner noted that mainstream adult services offered to an individual with intellectual disabilities were perceived as unequipped for their specific needs, suggesting a review of appropriate support pathways for similar future cases.
Addressed to: Northern, Eastern and Western Devon Clinical Commissioning Group; Seaton and Colyton Medical Practice
AI-generated concerns summaryThe coroner identified a lack of policy or guidance for psychiatric unit staff on actions to take when a patient refuses physical health observations, leading to uncertainty regarding MEWS calculation and when to seek medical assessment.
Addressed to: 5 Borough Partnership NHS Trust
AI-generated concerns summaryPrevious product recall notices contained shortcomings, prompting the coroner to identify a need for a new, comprehensive recall. This recall should detail all known problems and affected products, and be widely disseminated collaboratively.
Addressed to: Trading Standards
AI-generated concerns summaryThe coroner identified a lack of obstetric consultant supervision and a failure to consider surgical causes for abdominal pain following bariatric surgery. Concerns were also raised about poor clinical documentation, unaddressed urine dipstick findings, and a lack of specific guidance for managing pregnancy post-bariatric surgery.
Addressed to: Ashford and St Peter Hospital; CQC; General Medical Council; Medical Care Council; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner notes the Therapeutic Engagement and Observation Policy is not being rigorously followed by staff, leading to missed opportunities for escalating observation levels. A review of the policy is needed to implement automatic escalation to higher observation levels or one-to-one engagement after a serious event.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted a lack of practical experience and understanding among healthcare staff at HMP Doncaster regarding the signs and symptoms of malaria and tropical diseases.
Addressed to: Ministry of Justice; NHS England
AI-generated concerns summaryConcerns included a delay in labour progress assessment, lack of routine physiological observations by community midwives, and insufficient equipment. The maternity helpline was triaged by untrained staff, resulting in sepsis markers being overlooked and no structured call recording.
Addressed to: Kernow Clinical Commissioning Group; NHS England; Royal Cornwall Hospital, Treliske, Truro
AI-generated concerns summaryThe coroner identified a need for the routine use of respiratory rate bench-markers and oxygen blood monitoring in paediatric medicine, and improved recognition and action on red markers such as shortness of breath and blue lips.
Addressed to: Kernow Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner noted that private holiday lets with swimming pools were unregulated, the pool's profile presented a significant hazard due to a sharp slope, and the ratio of competent adults to children was inadequate and unenforceable.
Addressed to: Devon County Council; North Devon Council
AI-generated concerns summaryThe coroner identified that previous recommendations regarding ACCT case management for prisoners at risk of self-harm had not been rigorously implemented. This contributes to the continuing rise in suicides at HMP Woodhill, and there are concerns that a new prison-wide strategy will also not be adopted.
Addressed to: HMP Woodhill; Minister for Prisons
AI-generated concerns summaryThe coroner raised concerns about the ambulance service's significant resource issues, where demand consistently exceeds available capacity, requiring frequent activation of capacity management plans. Delayed patient handovers at hospitals further impact ambulance availability.
Addressed to: NHS Improvement; Department of Health and Social Care; East Midlands Ambulance Service; NHS England; NHS Hardwick
AI-generated concerns summaryThe coroner identified a lack of requirements for bus drivers transporting students to have Basic Life Support training or established emergency protocols. Concerns were also raised that Basic Life Support training is not part of the national curriculum for secondary education.
Addressed to: Department for Education; Department for Transport; Greenshades Coach Travel Ltd; George Abbot School; Surrey County Council
AI-generated concerns summaryStaff nurses lacked awareness of air embolization risks during uncapped and unclamped catheter changes, and there was a noted absence of literature or guidance on this specific procedural risk.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted concerns regarding the adequacy of the road layout, safety notices, and/or barriers on the A3075 road at Cottage, Perranwell, where multiple vehicles, including Mr Siddall's, had left the road. A review of this section is recommended to reduce the risk of further incidents.
Addressed to: Cornwall Council
AI-generated concerns summaryAvailability of psychiatric beds, resource allocation for the home treatment team's support threshold, and the management of psychological therapy waiting lists, particularly for high-risk patients, were noted as areas of concern.
Addressed to: Cornwall Partnership NHS Foundation Trust; NHS Kernow Clinical Commissioning Group