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 that the labelling and packaging of isopropyl nitrite, sold as 'English Room Odoriser', were inadequate under current CLP regulations, lacking updated hazard warnings, pictograms, precautionary statements, and a tactile warning.
Addressed to: Department of Business, Innovations and Skills; General Product Safety Department
AI-generated concerns summaryThe coroner noted a lack of verbal consultation between medical practitioners and custody sergeants regarding detainee concerns and observation levels. There is a need for joint training on observation levels, precise observation specification, and risks of drug and alcohol abuse in custody.
Addressed to: Department of Health and Social Care; G4S; National Police Chiefs’ Council; Nestor Primecare; Staffordshire Police
AI-generated concerns summaryInsufficient health and safety training for managers regarding their responsibilities and a lack of understanding of roles across the company were noted. The coroner also raised concerns about the absence of regular health and safety audits by qualified professionals.
Addressed to: Hugo Boss UK
AI-generated concerns summaryThe coroner noted a lack of blood pressure monitoring and no record of informing the patient about aortic aneurysm screening at HMP Dartmoor. There was also a delay in calling an emergency ambulance due to the absence of an emergency code protocol.
Addressed to: Dorset Healthcare University NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner identifies insufficient professional training to recognise self-harm in young people, a lack of systems encouraging young people to report peers, and gaps in multi-agency discussions, particularly for those resisting engagement.
Addressed to: Department for Education; Department of Health and Social Care; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner identified a serious design issue on the Kingsway/Metro system, contributing to numerous road traffic collisions, injuries, near misses, and two fatalities, which requires action from the Local Authority to improve safety.
Addressed to: Swansea Council
AI-generated concerns summaryThe coroner raised concerns that files were closed after letters instructing recipients to ignore them if no action was needed were sent, without verifying receipt or comprehension. Direct contact was also not made with a vulnerable individual to ensure they understood available help or to assess their capacity.
Addressed to: Norfolk County Council
AI-generated concerns summaryThe coroner noted a belief amongst nursing staff that 1:1 care could only be provided for a patient's mental health needs, rather than for their physical care needs or falls risk.
Addressed to: Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted that the prioritisation of falls activator device responses was subjective, leading to delays for individuals unable to respond verbally, and that staffing levels were insufficient to meet demand.
Addressed to: South Tyneside Council
AI-generated concerns summaryThe coroner identified that instrumental delivery guidance from the Royal College of Obstetricians and NICE was ambiguous, misleading, and lacked clear definitions for key terms like 'imminent' and 'gentle' traction. This ambiguity complicated decision-making during procedures and hindered the development of clear local Trust guidance.
Addressed to: Department of Health and Social Care; Pennine Acute Hospitals NHS Trust; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted a 10-minute delay in calling an ambulance after an emergency code, with the local protocol not followed. Similar issues with medical emergency responses, including incorrect codes and control room delays, have occurred at other prisons.
Addressed to: HMP Frankland; National Offender Management Service
AI-generated concerns summaryThe coroner identified gaps in the consistent review of patient medical history, previous imaging, and medication before invasive procedures and upon transfer from A&E. Concerns also include the need for respiratory consultant opinion before chest drain insertion, ensuring the respiratory team is informed, and training staff on accessing historical imaging.
Addressed to: Epsom and St Helier University Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the unregulated supply of Class A drugs, specifically Diacetyl Morphine in pill form, through internet sources and its importation via international postal systems, noting a lack of oversight.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted worsening ambulance response times, a significant staffing shortfall, and a lack of clear plans to address these issues. Concerns also include gaps in training for pregnancy assessment and patient extraction, and the non-implementation of suggested system improvements.
Addressed to: College of Paramedics; London Ambulance Service NHS Trust; NHS England
AI-generated concerns summaryThe coroner identified a lack of structured monitoring for patients experiencing discharge delays and an absence of a formal trust policy or guidance for late-night discharges, which could lead to inconsistent decisions.
Addressed to: Darlington Memorial Hospital
AI-generated concerns summaryStaff at William Harvey Hospital did not promptly liaise with the tertiary centre regarding Mr Willis's prior procedure, delaying necessary investigations with CT imaging to exclude complications.
Addressed to: East Kent Hospitals University NHS Trust
AI-generated concerns summaryInsufficient escalation of critical blood test results by the GP and laboratories delayed hospital admission and recognition of the serious condition. Further concerns included hospital staff's recognition of severity and a delayed high dependency unit transfer.
Addressed to: Central Manchester University Hospitals Trust; Davyhulme Medical Centre
AI-generated concerns summaryThe coroner noted a lack of basic first aid, CPR, and defibrillator training for prison officers and staff, alongside insufficient healthcare staff availability outside of core hours.
Addressed to: National Offender Management Service; NHS England
AI-generated concerns summaryThe coroner noted that information regarding firearms license holders was not consistently flagged on medical records and that there is no requirement for medical professionals to notify police of a license holder's deteriorating mental health.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified that many prison cell doors lack current anti-ligature strips due to no national retrofit programme. There is also an absence of a national pro forma for the ACCT process, leading to over-reliance on current risk assessment.
Addressed to: National Offender Management Service; Sodexo Justice Services