Browse 6,493 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified that guidance from the Welsh Assembly Government on reducing cot death was confusing, as it advised against bed-sharing if parents 'feel very tired,' a test deemed unrealistic.
Addressed to: Welsh Assembly Government
AI-generated concerns summaryThe revised training and flowchart for community hospital staff does not include a mechanism for obtaining emergency medical advice from experts in acute hospitals, which could be beneficial in urgent situations.
Addressed to: County Durham and Darlington NHS Trust
AI-generated concerns summaryCoroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Addressed to: General Medical Council; General Midwifery Council; Healthcare UK; HMP Belmarsh; Nursing and Midwifery Council
AI-generated concerns summaryThe coroner noted a delay in Mr Jones's acceptance by Worcestershire Royal Hospital likely impacted his survival. The hospital also lacked out-of-hours services for vascular surgery and interventional radiology.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that the lack of regulations in the UK requiring child-resistant fencing for private swimming pools could contribute to future child drownings.
Addressed to: Department for Education; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner noted that regular blood glucose testing might have led to earlier identification and management of diabetes, especially given the patient's risk factors. They raised concerns about the availability of specific medical guidance for staff on diabetes screening and management in similar circumstances.
Addressed to: Bilbrook Medical Centre; Springfield House Care Home
AI-generated concerns summaryThe coroner noted insufficient support for a newly qualified midwife assisting with a delivery and that midwife allocation did not consider individual experience. The 'Supervisors of Midwives' system at Bedford Hospital required urgent review.
Addressed to: Bedford Hospital NHS Trust
AI-generated concerns summaryThe coroner raises concerns regarding the ready availability and legal sale of synthetic cannabinoids, marketed as herbal incense but misused, noting they are dangerous and potentially life-threatening. A review of their status and control is requested.
Addressed to: Ministry of Justice; Advisory Council on the Misuse of Drugs; Home Office
AI-generated concerns summaryThe report identifies insufficient staffing for a high-risk falls patient, meaning one-to-one nursing was not consistently delivered. There was also a lack of handover material on falls risk between hospitals and no formal risk assessments after successive falls.
Addressed to: Abertawe Bro Morgannwg University Health Board; Health Inspectorate Wales
AI-generated concerns summaryThe coroner noted that Sussex Partnership Trust appeared unaware of their own protocols regarding City City.
Addressed to: Brighton and Sussex University Hospital Trust; Sussex Partnership
AI-generated concerns summaryConcerns were raised regarding inadequate advice to the patient on surgical risks, poor documentation of consent discussions, and missing patient information leaflets. The 'best interests' assessment proforma was incomplete, and questions were raised about delegating this assessment to a staff nurse.
Addressed to: Lancashire Teaching Hospital
AI-generated concerns summaryThe coroner noted that even if the deceased had been assessed as needing admission, no beds would have been available at Green Lane Hospital for his safety.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that a towpath gate, intended to be closed and locked when river levels reached 1.95 meters, was open despite higher water levels. There was no clear system for the Environment Agency to notify Shropshire Council of water levels, rendering the gate closure instruction ineffective.
Addressed to: Senior Lawyer Professional Support; Legal Services, Warrington; Shropshire Council
AI-generated concerns summaryThe coroner identified a risk of future deaths due to the public's use of Byway 11 as an informal car park near the A303. There is concern that addressing this issue at Byway 11 could cause the problem to shift to Byway 12.
Addressed to: Department for Transport; English Heritage; National Trust; Wiltshire Council; Wiltshire Landscape National Trust
AI-generated concerns summaryThe importance of clinic attendance was not explained, a cancellation letter was not sent, and urology referral documentation was absent. Junior doctors conducted specialist consultations, and a urologist did not review the patient despite suspected malignancy.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryConcerns were raised about the lack of direct communication between local offender managers and clinicians before issuing recall paperwork for hospitalized offenders, and confusion among probation staff regarding the correct recall process.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryIncomplete information transfer between children's services meant a high-risk referral was not fully assessed or led to a CAMHS appointment. A Youth Offending Team case was also not transferred after a change of address, preventing a timely referral order assessment.
Addressed to: Crown Prosecution Service; Department of Health and Social Care; Greater Manchester Police; Home Office; Lancashire County Council; MEDACS Healthcare; Ministry of Housing, Communities & Local Government; National Police Chiefs’ Council; Pennine Care NHS Foundation Trust; Police and Crime Commissioner - Greater Mancheste; Tameside Council
AI-generated concerns summaryRepeated falls occurred despite the deceased being identified as high risk, with one fall necessitating further surgery. A ward transfer also occurred at 1 am without a transfer document, preceding an unwitnessed fall.
Addressed to: Abertawe Bro Morgannwg University Health Board; Health Inspectorate Wales
AI-generated concerns summaryThe report highlights a lack of clear patient assessment before discharge and incomplete physiotherapy records. Further concerns relate to patients using inappropriate footwear for mobilisation, staff leaving patients mid-transfer, and inadequate training for those conducting incident investigations.
Addressed to: Calderdale and Huddersfield NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Mr. Camfield's agreed care plan, which stipulated one-to-one nursing care at all times, was not strictly followed by those involved in his treatment.
Addressed to: Mid Yorkshire Hospitals NHS Trust