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 identified a non-functional tracker system for slow-moving soldiers, of which senior commanders were unaware, and insufficient awareness and training regarding heat illness guidance (JSP539).
Addressed to: Special Forces; Defence
AI-generated concerns summaryThe coroner noted that the height of the walls of the steps accessing footbridge 57 allowed easy access to the railway tracks, creating a risk of future fatalities at this location.
Addressed to: British Transport Police; Network Rail
AI-generated concerns summaryThe coroner noted inconsistent record-keeping of service user engagement and a lack of a designated staff member with overall responsibility for reviewing risk assessments to identify trends. Concerns were also raised about ward rounds relying on brief summaries rather than the full care record.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Care Quality Commission
AI-generated concerns summaryThe coroner identified a need for more explicit guidance on how local healthcare providers advise pregnant women about whooping cough vaccination, including audit and follow-up. Additionally, national guidance is needed for effective communication among antenatal care providers.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified frequent failures in UHW's system for notifying GPs of patient admissions, despite an electronic system being in place. Concerns were also raised about providing adequate management support to overhaul this notification process.
Addressed to: University of Wales, Cardiff; University Hospital of Wales
AI-generated concerns summaryThe coroner noted the absence of an out-of-hours on-call rota for GI Radiologists to perform urgent procedures like percutaneous cholecystostomy, identifying this as a national issue that poses a risk to patient management.
Addressed to: Department of Health and Social Care; Salford Royal NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding a clinical determination made by SEPT without a face-to-face mental health assessment or sufficient inquiry, overriding the patient's GP's request. The report also invited NICE to reconsider its guideline on this matter.
Addressed to: First Response Team, South Essex Partnership University NHS Foundation Trust; NICE
AI-generated concerns summaryThe coroner noted incomplete and inaccurate nursing tools, assessments, records, and discharge summaries. Despite audits by the Trust to improve record keeping, no material improvement in standards was observed.
Addressed to: Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe Merlin database is complex and lacks prominent risk information on its front screen, contributing to communications officers' difficulty in identifying risks. Refresher training for officers using the database is also needed.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe care home did not obtain a complete record of prescription drugs from the resident's GP, resulting in some medications not being administered.
Addressed to: Springfield Care Home
AI-generated concerns summaryThe coroner noted short-term funding for the specialist Eating Disorder Service and a national lack of inpatient beds for mentally ill children. Gaps were also identified in school nurses' attendance at Multi-Disciplinary Meetings due to funding, impacting communication with education staff.
Addressed to: Department for Education; Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted concerns regarding the limited operating hours of the local fire station, which resulted in a delay in fire service arrival and prompted unqualified individuals to attempt a rescue, placing themselves at risk.
Addressed to: Greater Manchester Fire and Rescue Service
AI-generated concerns summaryThe coroner identified concerns regarding inadequate adherence to the deceased's pressure sore management plan, with missed turns and falsified records. Additionally, staff were inadequately trained in pressure mattress management, and a fault alarm on the mattress had been turned off, impacting its function.
Addressed to: New Park Residential Home; Stoke-on-Trent City Council
AI-generated concerns summaryConcerns were raised regarding physiotherapy that likely contributed to tissue breakdown after surgery, and the unavailability of working fibre optic equipment for intubation during a critical procedure. Nurses also did not promptly identify obvious post-operative swelling.
Addressed to: BMI Healthcare Limited
AI-generated concerns summaryPrison officers were either unaware of or did not follow the requirement to elicit a response from prisoners when unlocking cells, and they were also not consistently receiving or reading Prison Service Orders.
Addressed to: HMP Swaleside
AI-generated concerns summaryThe coroner noted insufficient regard for injured third parties immediately after impact in police pursuits, with inadequate follow-up regarding their welfare. Concerns were also raised about the lack of evidence that lessons from previous police pursuit deaths had been learned, and the inadequacy of police officer refresher training on pursuits.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner noted the inappropriate placement of a vulnerable individual in a residential care home that lacked nursing care and pressure sore training for staff. There was concern that availability was prioritised over the suitability of the placement, and formal guidance is needed for agencies.
Addressed to: Department of Health and Social Care; Littleborough Care Home; Pennine Care Trust; Rochdale Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted soldiers' lack of understanding of Kings Trailer brake release mechanisms and the Packet Commander's insufficient training in coupling. Concerns also highlighted the absence of safer alternative trailer extraction methods and questioned the Ministry of Defence's rationale for this.
Addressed to: Ministry of Defence
AI-generated concerns summaryCritical information from a paramedic's verbal handover to an A&E triage nurse was lost. Additionally, the Ambulance Trust did not notify the Hospital Trust of their presence within the hospital grounds while searching for the individual, which could have aided communication.
Addressed to: Department of Health and Social Care; Messrs. Weightmans; North West Ambulance Service
AI-generated concerns summaryThe coroner identified senior management's apparent unawareness of previous PFD reports concerning physical health care on mental health wards, with insufficient progress on establishing domiciliary consultant physician visits. Concerns were also raised about inconsistent follow-up for glucose testing of patients on antipsychotics.
Addressed to: South London and Maudsley Trust