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 summaryThe crossover point for westbound traffic lacks a slip road or deceleration lane, requiring vehicles to reduce speed significantly in the outside lane. There is also no signage prohibiting a right turn at this location.
Addressed to: Highways England
AI-generated concerns summaryThe coroner noted the absence of signage at a gap in the central reservation to indicate that it is no entry for eastbound vehicles or to prohibit U-turns and right turns for eastbound vehicles.
Addressed to: Highways England
AI-generated concerns summaryThe diagnosis of autonomic dysreflexia was not sufficiently highlighted in the patient's medical record, which meant a consultant physician was unaware of it during a subsequent hospital admission.
Addressed to: East Lancashire Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted that PEWS scores do not reflect current research into child illness and may distract doctors from recognising serious illness in children with low scores.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns that the deceased was not informed of his placement until the day before release, which may have increased his risk of drug use. There was also no protocol for continuing monitoring of vulnerable new arrivals at the hostel, leading to a significant delay in his discovery.
Addressed to: National Probation Service
AI-generated concerns summaryThe coroner identified a lack of effective leadership and support for junior staff on the labour ward, particularly in escalating concerns about an abnormal CTG trace and ensuring a consultant's prompt attendance. This contributed to a lack of understanding regarding labour ward management.
Addressed to: Milton Keynes Hospital
AI-generated concerns summaryPedestrians frequently cross a central reservation where a well-worn path indicates a serious risk, likely due to the nearest official crossing being 60 metres away and not clearly evident, raising concerns about the junction design.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted the patient was prescribed antidepressant medication for over five years without adequate review and was not offered additional therapies such as counselling or CBT.
Addressed to: New Court Surgery
AI-generated concerns summaryThe coroner noted the absence of documented medical advice provided by WWL to the Lakeside Unit, which impacts continuity of treatment. There were also differing interpretations of the Service Agreement between SBP and WWL, and no scheduled liaison meetings had taken place as required by the agreement.
Addressed to: 5 Boroughs Partnership NHS Trust; Wrightington Wigan & Leigh, Royal Albert Edward Infirmary; Department of Health and Social Care; Wigan Borough Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified a lack of risk assessment and documented consent for the use of lap belts on wheelchairs, noting unclear guidance on their use and the potential for them to be considered unlawful restraint.
Addressed to: Care Quality Commission; Risedale Estates Limited
AI-generated concerns summaryThe coroner noted Alexander House Health Centre's practice of prescribing concurrent antiplatelet and anticoagulant medications without seeking individual specialist advice, instead relying on general advice for other patients.
Addressed to: Alexander House Health Centre; Platt Bridge Health Centre
AI-generated concerns summarySignificant delays occurred in despatching an ambulance to an unconscious patient who had clearly suffered a serious head injury.
Addressed to: East Midlands Ambulance Services
AI-generated concerns summaryThe coroner noted national delays in X-ray reporting, attributing this to a shortage of qualified radiologists.
Addressed to: Department of Health and Social Care; Plymouth Hospitals NHS Trust; Social Services Truro Cornwall
AI-generated concerns summaryThe coroner noted the absence of compulsory inclusion of automatic water suppression systems (domestic sprinklers) in the design and building phases of residential properties, particularly those for vulnerable individuals, to enhance fire safety.
Addressed to: Department for Communities and Local Government
AI-generated concerns summaryThe coroner identified non-adherence to mandatory ACCT procedures for prisoners at risk of inadvertent self-harm, inadequate dissemination of medical information upon arrival, and gaps in healthcare staff's access to patient notes. There were also concerns about limited interaction with high-risk drug users.
Addressed to: Governor HMP Hewell; Worcestershire Health and Care Trust
AI-generated concerns summaryThe coroner identifies a lack of a central register for energy sources and service history in holiday accommodations, alongside insufficient health and safety checks conducted by appropriately qualified specialists. Concerns also include inadequate information for travellers about carbon monoxide risks and the need for stronger EU legislation on gas installations.
Addressed to: ABTA – The Travel Association; Louis Group including the Louis Corcyra Beach Hotel; The Federation of Tour Operators; Department for Culture, Media and Sport; Department of Trade and Industry; Foreign and Commonwealth Office; Thomas Cook Group
AI-generated concerns summaryThe coroner noted the importance of ensuring healthcare professionals are adequately trained in resuscitation and able to respond appropriately in the event of a patient collapse.
Addressed to: Ipswich Hospital
AI-generated concerns summaryThe coroner identified insufficient guidance and communication between sleep apnoea specialists and psychiatrists regarding CPAP use, sedative medication risks, and monitoring for Obstructive Sleep Apnoea (OSA) patients in psychiatric care.
Addressed to: Guys and St Thomas NHS Trust; Cambian Group
AI-generated concerns summaryThe coroner noted that street lighting was switched off at the time of the incident, reducing the pedestrian's chance of being seen and potentially surviving the collision.
Addressed to: Essex County Council; Essex Highways Agency
Addressed to: HMP Pentonville; London Ambulance Service NHS Trust; National Offender Management Service