Browse 6,493 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 summaryInsufficient maintenance of emergency pull-cords and smoke detectors in sheltered accommodation, including a disconnected pull-cord, was noted. The smoke detector system also did not alert the Emergency Control Room, and fire instructions were unclear, risking delayed emergency response.
Addressed to: Bristol City Council
AI-generated concerns summaryThe coroner identified that neither members of the public nor paid hunt staff are required to wear protective headgear complying with safety standards during hunting events, and the Master of Foxhounds Association recommendations currently permit non-compliant headgear.
Addressed to: Foxhound Association; Health and Safety Executive
AI-generated concerns summaryThe coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
Addressed to: Avon and Wiltshire Mental Health NHS Trust
AI-generated concerns summaryThe coroner noted staff were unaware of the falls prevention policy, leading to inadequate recording, escalation, and review of falls incidents. Additionally, patient observation forms were found to be inaccurate and documentation was not completed contemporaneously.
Addressed to: Sunrise care home
AI-generated concerns summaryThe coroner noted the absence of a pedestrian crossing at Ramshead Approach in Leeds, on a busy road (A6120) frequently used by pedestrians, including children.
Addressed to: Highways England
Addressed to: HMP Pentonville
AI-generated concerns summaryThe report identifies significant delays in psychiatric follow-up appointments and a lack of planned community support, compounded by poor communication between mental health teams and other stakeholders. Insufficient information was provided to the patient and family regarding care teams and contact points.
Addressed to: Leicester Partnership NHS Trust; Leicester City Council
AI-generated concerns summaryThe coroner noted a lack of recognition among clinicians regarding a specific medication's contraindication for asthma and the risks associated with a combination of psychotropic drugs. Concerns were also raised about the absence of routine ECG screening for prisoners prescribed this medication combination.
Addressed to: Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner identified a lack of policy clarifying responsibilities and communication channels between Sunderland and County Durham and Darlington NHS Trusts for patient referrals. There were also poor communication levels and a poor understanding of differing practices between medical professionals at the two trusts.
Addressed to: City Hospitals Sunderland NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an ACCT was closed without consultation with healthcare, chaplaincy, or management. Concerns were also raised about whether only the person primarily responsible for a prisoner's ACCT should be authorised to close it.
Addressed to: HMP and YOI Doncaster
AI-generated concerns summaryThe coroner noted pregnant patients with mechanical heart valves sometimes receive insufficient Clexane doses and inadequate anti-factor Xa monitoring. There was also a lack of understanding among clinicians across the region regarding the increased thrombosis risk for these patients, potentially delaying diagnosis.
Addressed to: Birmingham Women’s NHS Trust; British Cardiovascular Society; N.I.C.E; Royal College of Obstetricians and Gynaecologists; Royal College of Physicians; University Hospitals Birmingham NHS Trust
AI-generated concerns summaryPlanning documents for a specific construction task did not recognise a different methodology and lacked critical instructions for the procedure. Additionally, some site witnesses with pivotal roles did not demonstrate a clear understanding of the processes or basic terminology.
Addressed to: CMF Limited; Laing O’Rourke UK & Europe
AI-generated concerns summaryThe coroner notes concerns regarding the process of granting home leave without a recent doctor's review or updated risk assessment. The report identifies a lack of clear, trust-wide policy detailing specific requirements, staff awareness, and auditing for adherence.
Addressed to: Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner identifies concerns regarding the lack of a legal requirement or reliable system for tracking child GP registration and de-registration. This creates potential safeguarding risks, especially for children with chronic health needs, and specialist teams were not informed of Harry's de-registration.
Addressed to: Department of Health and Social Care; General Medical Council; Nottingham City Clinical Commissioning Group; Nottinghamshire Safeguarding Children Board; Public Health England
AI-generated concerns summaryThe coroner noted that placing towels over doors could conceal patient attempts to cause themselves harm and prevent proper staff monitoring. This practice should be reviewed, and alternative methods for patient privacy considered.
Addressed to: Devon Partnership Trust
AI-generated concerns summaryIncompatible electronic patient record systems and delays in reviewing paper records during transfers between medical practices meant a patient's serious psychiatric illness and lack of medication were not identified during health checks.
Addressed to: Greater Manchester NHS Area Team
AI-generated concerns summaryThe coroner noted a lack of appropriate escalation of clinical care in the obstetric department and insufficient processes for information sharing and coordinated care between various community and hospital services for post-natal patients.
Addressed to: Gloucestershire Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding insufficient information transfer during hospital referrals, specifically noting a lack of clear procedures for junior doctors completing forms and for receiving teams to proactively address incomplete clinical information.
Addressed to: Leeds Teaching Hospitals NHS Trust; Mid Yorkshire NHS Trust
AI-generated concerns summaryThe coroner raises concerns that the quality of street lighting at the incident location may have contributed to the incident.
Addressed to: Essex Highways Agency
AI-generated concerns summaryA Mental Health Act assessment was not conducted when Mr. Abel expressed suicidal intention, and there was inadequate communication with his family about his mental health relapse and the expectation for his safe keeping.
Addressed to: Leicester Partnership NHS Trust