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 coroner noted insufficient space for segregating mixed traffic, a confusing contra-flow cycle lane, and unclear signage. Concerns were also raised about the road layout encouraging pedestrians onto the cycle path and weak Highway Code guidance regarding pedestrian use of cycle paths.
Addressed to: Secretary of State for Transport; Trafford Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted insufficient supervision to recognise a collapse and an inadequate resuscitation attempt in a gym setting. Concerns included a lack of adequate risk assessment for users, qualified first aiders, and formal national guidance for fitness centres.
Addressed to: Health and Safety Executive
AI-generated concerns summaryConcerns were raised regarding a delay in rescue because a standby diver could not locate a c-clip on a harness. The coroner questioned if checking this c-clip should be part of pre-dive protocol checks.
Addressed to: SubCPartner
AI-generated concerns summaryThe junction design at Deansgate and Knowsley Street, featuring a 90-degree bend and restricted driver visibility, creates risks for pedestrians crossing outside designated areas. Concerns also relate to insufficient pedestrian crossing time and the absence of guard rails to guide pedestrians to the crossing.
Addressed to: Bolton Council
AI-generated concerns summaryThe coroner noted a lack of uniform practices across GP surgeries for monitoring District Nurse Teams' compliance with delegated INR testing, posing a risk of unmonitored over-anticoagulation. Without action, there remains a risk of future deaths in similar circumstances.
Addressed to: England and Wales; Cwm Taf Morgannwg University Health Board; National Assembly for Wales; Practice 1, Keir Hardie Health Park
AI-generated concerns summaryThe coroner identified a lack of care staff training regarding the mobility, handling, and care of residents on PEG feed regimes. There was also a failure to report an incident of projectile vomiting during PEG feeding to the care home manager.
Addressed to: Orchard Care Homes The Hamlet
AI-generated concerns summaryThe coroner identified a lack of defibrillator (AED) availability at the training site and insufficient AED training. Concerns were also raised about inadequate communication checks between staff and cadets after nightfall due to unclear policy guidance.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted a lack of formal guidance and training for prison healthcare staff regarding decisions on restraints and compassionate release for terminally ill prisoners, which could delay transfers and compassionate release.
Addressed to: HMP Exeter; HMP Portland
AI-generated concerns summaryThe coroner noted the impracticability of Prison Service Instruction 64/2011 on daily doctor visits for prisoners under continuous observation, and a lack of national guidance to address this. ACCT review attendees lack specific instruction to read ongoing observations, risking missed information.
Addressed to: Equalities, Rights and Decency Group, The Ministry Of Justice
AI-generated concerns summaryThe coroner noted staff at Bourne House were unaware of policies for reporting falls and contacting emergency services, raising concerns about the lack of clear, regularly reviewed training on addressing falls.
Addressed to: Bourne House
AI-generated concerns summaryThe coroner identified issues with a Clinical Advisor's assessment and advice, as well as insufficient welfare calls. Concerns were also raised about the adequacy of training, competency assessment, and auditing for Clinical Advisors, noting a lack of a safety net for identifying risks.
Addressed to: Care Quality Commission; South Western Ambulance Service NHS Foundation Trust ('SWASFT')
AI-generated concerns summaryThe coroner noted a lack of a formal national monitoring scheme for inexperienced surgeons carrying out procedures. Consideration should be given to developing a national scheme, using the Queen Alexandra Hospital's model as an example of good practice.
Addressed to: Dept. of Health
AI-generated concerns summaryThe coroner raised concerns regarding the availability of psychiatric beds on Dovedale, as Mr Robinson required a bed but none were available before his condition deteriorated.
Addressed to: Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns that insufficient consideration was given to balancing the acute needs and risks of a vulnerable individual, who relied heavily on family, when decisions were made to restrict their communication with family members.
Addressed to: Police of the Metropolis
AI-generated concerns summaryThe coroner identified a lack of clarity regarding the purpose, operation, and training of the school's pastoral team, noting the system was insufficiently robust to address the student's needs.
Addressed to: Hewett School
AI-generated concerns summaryThe coroner identified suboptimal hospital staffing levels, issues with staff shortage escalation procedures, and insufficient staff training in drug administration and cardiac arrest response.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe care home had no system for reassessing residents when Deprivation of Liberty Safeguarding orders expired, which could lead to a lack of legal authority and insufficient observation. The absence of CCTV also hampered the subsequent police investigation.
Addressed to: Birmingham City Council; Care Quality Commission
AI-generated concerns summaryThe Transfer of Care Form was incomplete and contained inaccurate information. It was not provided to escorting police officers at the time of examination for immediate access by the custody nurse.
Addressed to: North Wales Police; BCUHB, Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted safety concerns regarding a zebra crossing's proximity to a busy mini roundabout and store entrance. An expert suggested relocating the crossing further away and installing pedestrian barriers to enhance safety.
Addressed to: J. Sainsbury PLC; Trafford Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted inadequate staff training at Hurst Hall regarding emergency call procedures, arranging GP visits for unregistered residents, CQC reporting, and maintaining proper care records. Concerns were also raised about gaps in Out of Hours doctors' training on record-keeping, vital signs assessment, and coroner reporting.
Addressed to: GTD Healthcare; Hurst Hall Care Centre