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 summaryMrs Harris was not seen by a doctor before discharge from the Minor Injuries Unit, anticoagulant therapy was not considered, and the potential effects of immobility were not assessed.
Addressed to: Mount Vernon Hospital
AI-generated concerns summaryThe coroner identified that the sale of e-cigarette fluid is not regulated or licensed.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryCare plans for clients with swallowing difficulties, specifically their feeding regimes, were reviewed quarterly, which was insufficient to adjust diets to changing abilities. More frequent examination of these plans was required.
Addressed to: Westwood Homecare Limited
AI-generated concerns summaryPolice gave insufficient consideration to the risk of death from prolonged restraint in individuals experiencing acute behavioural disturbance.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted a gap in the RSSB Rule Book, which permits trains to be stopped only when a person may damage a train, but not when a person is in danger from a train.
Addressed to: Rail Safety and Standards Board
AI-generated concerns summaryConcerns were raised regarding the lack of prominent 20 mph speed limit signage on London Bridge and the absence of a separate cycle lane for improved safety.
Addressed to: for information); Transport for London
AI-generated concerns summaryPolice did not pass on significant reported remarks about a perpetrator, meaning a psychiatric nurse was unaware of this key information during assessment. Consequently, the individual was assessed as zero risk and discharged with limited follow-up, despite a history of self-harm and a recent suicide attempt.
Addressed to: Cumbria Constabulary; Cumbria Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a failure to immobilise a patient with suspected spinal injury, despite symptoms and fall risk, and that the hospital triage process did not adequately re-assess the risk. This led to a five-hour delay in diagnosis.
Addressed to: Care Quality Commission; Dudley Group NHS Foundation Trust; West Midlands Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding poor quality handwritten medical and nursing notes, a radiologist's observation of a foreign body not being acted upon by treating doctors, and the lack of a satisfactory swab count policy during surgical procedures.
Addressed to: Department of Health and Social Care; University Hospital of South Manchester
AI-generated concerns summaryConcerns were raised regarding the inconsistent following of systems for family communication and the absence of an auditing process. The coroner also noted variable staff understanding and adherence to the early discharge plan.
Addressed to: Rotherham, Doncaster and South Humber NHS Foundation Trust
AI-generated concerns summaryThe crisis team failed to adhere to Mr Daniels' visit plan or document non-compliance, and had communication issues. Concerns were also raised about delays in crisis house referrals and insufficient consideration of hospital admission despite high-risk factors.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a clear and accessible protocol for staff to access equipment for flexible sigmoidoscopies out of hours. This issue persisted 18 months after the death, indicating a need for expedited action.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the driver had insufficient experience in controlling the vehicle during difficulties, despite being qualified. There was also a practice of commanders not wearing safety harnesses and a lack of enforcement of standing orders by senior officers.
Addressed to: Minister of Defence; British Army; the suppliers of the software
AI-generated concerns summaryThe ambulance service's call script for breathing difficulties does not include a question about chest pain, which can lead to inappropriate call prioritisation. This omission can delay the allocation of an urgent response.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of awareness among employers and employees about mental health issues in the workplace, particularly regarding disciplinary processes. There is scope for ACAS guidance to be enhanced and better publicised to address this.
Addressed to: Advisory, Conciliation and Arbitration Service
AI-generated concerns summaryThe coroner identified a lack of policy for staff actions when a patient is not found within a 10-minute observation period. Concerns also noted the practical challenge of one staff member managing hourly checks for multiple patients alongside 10-minute observations.
Addressed to: Avon and Wiltshire NHS Partnership Trust
AI-generated concerns summaryThe coroner noted concerns about the emergency medical dispatcher's confusing questioning method to ascertain a patient's consciousness. The report suggests a more direct follow-up question, such as "Can you wake him?", would be more appropriate.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryConcerns included incomplete reporting by West Yorkshire Police of road traffic collision findings to Kirklees Council, a lack of clear responsibility for risk assessments at collision scenes, and inconsistencies in Kirklees Council's road inspection methods.
Addressed to: Kirklees Council; West Yorkshire Police
AI-generated concerns summaryThe coroner noted the lack of effective security equipment preventing access to the station and tracks after hours, and the ease with which Mr Hoare could access the area by climbing through widely spaced tape.
Addressed to: National Rail
AI-generated concerns summaryThere is a lack of formal regulation for non-medical providers of circumcision services, which the coroner notes could lead to future deaths.
Addressed to: Care Quality Commission