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 summaryUpon discharge after a head injury, the deceased's home circumstances, including the lack of an observer, were not assessed as recommended by NICE guidelines. There was also no documented assessment of discharge risk factors in the deceased's records.
Addressed to: Department of Health and Social Care; Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe practice lacked software for prescription decisions, a system for notifying missed INR tests, and failed to maintain an anti-coagulation register. Additionally, the coroner noted a failure to inform the pharmacy of Warfarin withdrawal when INR safety testing was not conducted.
Addressed to: Aneurin Bevan University Health Board; Cwm Taf University Health Board; National Assembly for Wales; North Community Mental Health Team; Lawn Medical Practice
AI-generated concerns summaryThe coroner identified significant shortcomings in the police investigation, including a lack of inquiry into missing items, failure to verify the source of blood at the scene, and overlooking a critical laceration that contributed to death. This reflected an insufficient level of thoroughness in evidence collection.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner notes an absence of a system requiring residential home managers to seek advice from Social Services before discharging residents, raising concerns about ensuring resident safety and welfare after discharge.
Addressed to: Cumbria County Council; Green Lane Care Homes Limited
AI-generated concerns summaryThe coroner identified concerns regarding an off-duty police officer contaminating a death scene and the subsequent failure of attending on-duty officers to secure the scene or remove their colleague.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner identified concerns regarding a significant delay in gaining entry to premises and the absence of a clear policy for forced entry in such emergencies. There were also issues with the initial police investigation, which did not adequately find evidence or consider all potential scenarios.
Addressed to: Greater Manchester Police
AI-generated concerns summaryA communication breakdown meant an MRI scan was declined due to an uncommunicated consent requirement, potentially impacting the patient's care. Tighter controls are needed for requisitioning procedures like MRI and CT scans to avoid confusion and prevent failed procedures.
Addressed to: University Hospital of North Staffordshire
AI-generated concerns summaryThe coroner identified insufficient qualifications for staff assessing psychiatric referrals and noted gaps in the completion and communication of risk assessments, including suicide risk, within mental health teams, exacerbated by a lack of continuity of care.
Addressed to: Central and North West London NHS Foundation Trust
AI-generated concerns summaryWestminster City Council's inspections failed to identify a missing road sign and defective lighting for an existing sign over three years, partly because these assets were not fully recorded on their database. The inspection system and asset database were not sufficiently comprehensive to identify such defects.
Addressed to: City Of Westminster
AI-generated concerns summaryThe coroner identified insufficient escalation protocols for suspected stroke patients across primary care, bed bureau, and ambulance services, leading to delays in emergency response and risking timely diagnosis and treatment options.
Addressed to: East Midlands Ambulance Service; NHS England; University Hospital Leicester
AI-generated concerns summaryThe coroner noted staff training needs at Lord Hardy Court EMI Residential Home concerning head injury protocols and seeking social worker input. Concerns were also raised regarding the sufficiency and objectivity of initial safeguarding referral screenings and the monitoring of high-risk residents.
Addressed to: Rotherham Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted that current aviation safety regulations do not mandate all aircraft to carry essential medical equipment, including defibrillators, airway adjuncts, and suction equipment, which medical experts deem critical for passenger survival during a cardiac arrest.
Addressed to: Civil Aviation Authority; European Aviation Authority; Irish Aviation Authority
AI-generated concerns summaryThe A&E doctor's assessment did not adequately consider the risk of internal bleeding for a patient with trauma and multiple fractured ribs, who was also receiving anticoagulation therapy.
Addressed to: East Kent Hospitals University NHS Trust
AI-generated concerns summaryThe coroner noted there is no formal requirement for surgeons to acknowledge they have read and understood relevant hospital guidelines and those from bodies like NICE.
Addressed to: Cwm Taf University Health Board; National Assembly for Wales
AI-generated concerns summaryThe coroner raised concerns regarding inadequate resourcing and lack of preparation within HMP Rye Hill's healthcare department following its re-roll, leading to substandard care. Similar issues could arise in future national re-rolls of prisons.
Addressed to: HMP Parc; HMP Rye Hill; National Offender Management Service; The Chief Coroner
AI-generated concerns summaryThe coroner noted concerns regarding a consultant neurologist working excessive hours, including 7 days a week, which presented an increased potential for errors.
Addressed to: University Hospital North Midlands
AI-generated concerns summaryThe coroner notes concerns that an easily accessible wall, where previous deaths have occurred, poses a risk of further deaths and danger to visitors who might use it as a seating area, particularly after consuming drink or drugs.
Addressed to: Hammerson Plc
AI-generated concerns summaryThe coroner noted insufficient staffing levels at HMP Wormwood Scrubs prevented the implementation of a nominated Officer scheme, despite previous recommendations from the Prisons Ombudsman.
Addressed to: HMP WORMWOOD SCRUBS
AI-generated concerns summaryThe RSSB Rule Book limits stopping trains only to prevent damage, not to protect individuals in danger on the line, and a cautioned train still struck the person.
Addressed to: Rail Safety and Standards Board
AI-generated concerns summaryThe coroner identified the absence of an electronic system for recording cell bell calls, leading to inconsistent recording of medical matters. They also noted insufficient guidance to ensure single healthcare staff carried a radio, potentially delaying emergency responses.
Addressed to: HMP Wayland