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 removal of railings at the end of Fountain Street encouraged pedestrians to cross Ball Haye Street at an unsafe 'Keep Clear' point, bypassing the pedestrian crossing. The coroner requested the council review the area for possible modifications, such as reinstating railings.
Addressed to: Staffordshire County Council
AI-generated concerns summaryThe coroner noted the absence of life rings at Lock 19 on the Calder Canal and requested the trust to reassess the appropriateness of their installation at this location.
Addressed to: Canal River Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of control over the amount of Oramorph medication prescribed. While its morphine content falls below the threshold for controlled drug requirements, large quantities present a serious risk to health and are subject to abuse.
Addressed to: Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe coroner noted insufficient deviation markings on a road bend, a tree trunk near the carriageway that posed a danger to cyclists, and a slippery path surface that could cause walkers to slip into the road.
Addressed to: Tandridge District Council
AI-generated concerns summaryThe coroner noted a lack of service provision for psychotherapy care for individuals with anti-social personality disorder. This gap in provision was identified as posing a risk of future deaths.
Addressed to: North East London Foundation Trust Goodmayes Hospital; Redbridge Clinical Commissioning Group
AI-generated concerns summarySystems within BCUHB are not sufficiently robust to ensure staff are appropriately qualified for their roles and that their training and qualifications remain up to date.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted delays in Second Opinion Appointed Doctor (SOAD) appointments for Electroconvulsive Therapy (ECT), raising concern that urgent powers under s62 MHA are becoming a default due to potentially insufficient SOAD numbers.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a potential drug interaction between Miconazole Gel and Warfarin, which can increase bleeding risk. There is a lack of awareness of this interaction among health professionals and difficulty in locating clear information.
Addressed to: BMA; General Dental Council; NHS England: Wales and Scotland; Royal College of GPs; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner identified ineffective Occupational Health support and delays in accessing a doctor. Concerns were also raised about the Fire and Rescue Service requiring the deceased to take on extra duties despite knowing he was suffering, indicating insufficient support for staff in stressful situations.
Addressed to: Greater Manchester Fire and Rescue Service
AI-generated concerns summaryThe coroner identified a delay in diagnosing a patient's tibia and fibula fractures, which remained undiagnosed for several days despite regular GP and nurse visits, leading to extreme pain for the patient.
Addressed to: County Durham and Darlington NHS Trust, Grosvenor Park Care Home; Neasham Road Surgery
AI-generated concerns summaryThe coroner raised concerns regarding a hospital policy that does not routinely perform CT scans for elderly patients with suspected fractures due to radiation risk, despite the higher risk of missing such injuries. The report asks if this policy can be amended.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryInsufficient falls risk assessment, incomplete or lost neurological observation charts, and a lack of inter-disciplinary reading of patient notes were identified. The immediate shredding of handover sheets and inadequate incident reporting were also concerns.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate information sharing regarding an individual's repeatedly stated intentions to end his own life between the custody record, the investigating officer, and the Crown Prosecution Service. This led to a significant under-reporting of suicide/self-harm risk during bail consideration.
Addressed to: West Mercia Constabulary
AI-generated concerns summaryThe coroner noted concerns that the chamfered kerb design may have contributed to the vehicle overturning, and the absence of a protective barrier on the central reservation could have altered the vehicle's trajectory.
Addressed to: Stockport Council
AI-generated concerns summaryA divergence exists in guidelines and practice between hospital Trusts and consultants compared to National Institute for Health and Care Excellence (NICE) recommendations for managing prolonged rupture of membranes and Group B Streptococcus screening in pregnant women, particularly concerning antibiotic usage.
Addressed to: Department of Health and Social Care; National Screening Committee; N.I.C.E; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner identified a lack of widespread awareness among cardiologists and device manufacturers regarding the risk of air entering the vascular system during a specific cardiac procedure when performed under conscious sedation. This unknown risk could lead to future complications for patients at other Cardiac Centres.
Addressed to: British Cardiac Intervention Society; British Society of Interventional Radiology
AI-generated concerns summaryThe coroner noted that clinicians should inform police about self-discharged patients requiring further investigation, and raised issues regarding West Yorkshire Police custody staff's knowledge of relevant acts and codes, as well as staffing levels during high demand.
Addressed to: St James’s University Hospital; West Yorkshire Police
AI-generated concerns summaryThe coroner identified concerns with the effectiveness of office systems for receiving hospital discharge summaries advising medication review, specifically that a GP review of Christopher's medication did not take place.
Addressed to: Wibsey and Queensbury Medical Practice
AI-generated concerns summaryThe coroner noted concerns regarding the required training levels for staff changing children's tracheostomy tubes and the lack of medical presence during the procedure. The policy for failed tube replacement directs emergency transfer instead of an on-site emergency tracheostomy.
Addressed to: Epsom and St Helier, University Hospitals NHS Trust; Queen Mary’s Hospital for Children
AI-generated concerns summaryThe coroner noted that current vaccination policy does not include males against a viral infection, which poses a risk of future deaths in men from the consequences of this infection.
Addressed to: Joint Committee on Vaccination and Immunisation; Department of Health and Social Care