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 about the GMP computer system hindering officer access to information and a failure to record pertinent intelligence on individual profiles. There were also issues with call escalation procedures and understanding the MMU's role in enquiries.
Addressed to: Greater Manchester Police
AI-generated concerns summaryConcerns were raised regarding delays in confirming the diagnosis of sigmoid colon obstruction, in the decision for stenting, and in undertaking surgery. These delays led to the patient's condition deteriorating and diminished her chances of survival.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe report notes that staff did not adjust the prescribed and administered paracetamol dosage for Ms Clark, despite her extremely low body weight.
Addressed to: Rotherham Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted staff applied for DOLS while the person was detained under the Mental Health Act, raising concerns about insufficient understanding of DOLS applications. This included their place-specific nature and their appropriate use for compliant patients in palliative care.
Addressed to: Greater Manchester West Mental Health NHS Foundation Trust; Trafford Council
AI-generated concerns summaryThe report describes uncoordinated risk assessments between hospital staff and police officers observing a patient, and a lack of communication. This led to police misunderstanding the hospital layout and an insufficient safety plan for the patient, other patients, visitors, and staff.
Addressed to: Department of Health and Social Care; Greater Manchester Police; Home Office; Leigh NHS Foundation Trust; Wrightington Wigan
AI-generated concerns summaryThe coroner noted insufficient processes for sharing and reviewing historical prisoner information and risks between staff and healthcare departments. Specifically, healthcare staff were not consistently informed of prisoners with an ACCT history or provided with Prisoner Escort Records upon arrival.
Addressed to: Government Legal Department; Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe hospital did not conduct a serious untoward incident review or root cause analysis, and a recognised need for a consultant-led out-of-on-call rota for post-surgical patients has not been implemented.
Addressed to: University Hospital of North Midlands
AI-generated concerns summaryThe Trust's internal investigation did not fully identify failures in basic medical care, including a lack of appropriate one-to-one supervision for a patient with acute confusion and blindness, and inadequate information handover between shifts.
Addressed to: North Manchester General Hospital
AI-generated concerns summaryThe coroner noted insufficient steps to assess and act upon Mr Smith's vulnerability following a fall. Concerns were raised about reviewing the admissions policy for resident suitability and the falls risk assessment policy with associated staff training.
Addressed to: Village Nursing and Care Home
AI-generated concerns summaryThe London Ambulance Service's call triage protocol does not require call handlers to explicitly ask about the "type of fit," only completing the section if the caller offers the information, which the coroner suggests may need amendment.
Addressed to: London Ambulance Service
AI-generated concerns summaryThe coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
Addressed to: Blackpool Teaching Hospitals NHS Trust; Care Quality Commission
AI-generated concerns summaryThe coroner identified a lack of clarity regarding pressure testing activities and raised questions about compliance with work equipment regulations and HSE guidance across the industry.
Addressed to: AGD Equipment Limited; Construction Plant Hire Association
AI-generated concerns summaryThe coroner noted a presumption in favour of vaginal delivery, influenced by cost considerations, which required re-evaluation.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryBedrail mechanisms at the care home sometimes did not fully engage, creating a fall risk. After a significant fall, staff moved a patient without fully assessing for head and spinal trauma.
Addressed to: Ranc Care Home Ltd
AI-generated concerns summaryThe coroner noted a lack of risk assessment training for senior staff, who relied on their experience over Health & Safety Executive documentation. Concerns were also raised about staff not fully recognising task-related risks and the absence of a comprehensive emergency plan on the farm.
Addressed to: Maurice Mason Ltd
AI-generated concerns summaryThe coroner identified gaps in information sharing regarding a patient's dementia between Basildon Hospital and outsourced services, as private providers lacked access to the hospital's patient record system. This meant transport and phlebotomy services were unaware of the patient's condition.
Addressed to: Basildon Hospital Trust
AI-generated concerns summaryThe report highlights the lack of a warning sign for a left-hand bend on a road section, contrasting with signage in the opposite direction, and notes the bend's obscured visibility until after a hill crest.
Addressed to: Devon County Council; Devon Highways
AI-generated concerns summaryThe coroner raises concerns regarding the safety of the staggered junction of the A16 with the B1166, noting multiple fatalities and injury-producing collisions. Similar safety issues have been observed at other staggered junctions in Lincolnshire.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner raises concerns about the absence of a safe or controlled means for pedestrians to cross the A25 Guildford Road in Abinger Hammer village.
Addressed to: Surrey Local Highways Services Group Manager
AI-generated concerns summaryThe coroner identified a lack of appropriate lighting on the A1018 slip road to assist motorists in identifying sudden hazards. Concerns also included the absence of signage warning motorists of flood risk on the slip road.
Addressed to: Durham County Council