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 raised concerns that information in ambulance records, indicating a patient had not eaten for five days, was not reviewed during the MUST screen, potentially leading to a missed referral to dietetic services in other cases.
Addressed to: James Paget University Hospital NHS Foundation Trust
AI-generated concerns summaryThere was no direct mechanism for the hospital to notify the fire service of high-risk home oxygen users who smoke, as the oxygen supplier's system prevented full disclosure of the smoking risk. This meant the patient was not assessed for specialist safety equipment, highlighting a need for improved inter-agency communication.
Addressed to: Air Liquide; Lincolnshire County Council; NHS Lincolnshire West Clinical Commissioning Group; United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the lack of ready access to essential pressure sore dressings for nursing homes and community nurses, as ordering through a GP could take up to 14 days.
Addressed to: NHS Coastal West Sussex Clinical Commissioning Group; Sussex Community NHS Trust
AI-generated concerns summaryThe coroner noted a lack of continuity in crisis team care, where the patient repeatedly recounted personal history. Concerns also related to insufficient discussion of treatment options and efficacy, and a delay in providing urgent help.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner noted poor lighting and inadequate signage at the Langmeads foot crossing. These issues increase the risk to pedestrians, especially those distracted by headphones or phones, who may not perceive approaching high-speed trains.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified deficiencies in police custody procedures, noting inadequate risk assessments for intoxicated detainees, a failure to maintain regular rousing checks, and insufficient training for detention officers on the risks of sobering individuals.
Addressed to: South Yorkshire Police
AI-generated concerns summaryThe coroner identified deficient nurse training and understanding of Type 1 Diabetes, alongside a lack of specialist outreach nurse advice and insufficient consultant cover. Concerns also included staff unawareness of available equipment and a significant delay in patient transfer.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that service engineers lacked specific training and equipment to identify a defect in the Minivator 2000 stairlift. Additionally, no national safety recall had been issued to alert end-users or the wider industry to the product's risks.
Addressed to: British Healthcare Trades Association; Handicare Accessibility Ltd
AI-generated concerns summaryThe coroner noted a lack of national police understanding and training on managing acute behavioural disturbance during restraint, and raised concerns that multi-agency mental health crisis teams and patient conveying policies from West Midlands have not been adopted nationally.
Addressed to: National mental health working group; Association of Ambulance Chief Executives; Association of Chief Police Officers; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the free availability of large volume helium canisters, with no controls on individual purchases and no modified control valves to restrict gas release.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryMedical staff were caring for significantly more patients than a safe ratio, leading to an overstretched team and deficiencies in care. Neuro observations were not performed according to guidance, and poor note-taking caused communication issues between nursing and medical teams.
Addressed to: Cardiff and Vale NHS Trust
AI-generated concerns summaryThe coroner noted concerns that the pedestrian crossing's positioning on the apex of a sharp bend was contributory to the death, with suggestions for relocation or traffic light control.
Addressed to: Coventry City Council
AI-generated concerns summaryThe coroner identified that smoke alarm covers were left in place after fitting, potentially preventing them from activating, and notes alarms were often inaccessible due to their ceiling location.
Addressed to: Home Office
AI-generated concerns summaryThe coroner raised concerns regarding the safety of the road junction at Upper Kings Street and Regent Road, Leicester, identifying issues with visibility, absent or inadequate filter lanes, heavy traffic, and the road's contour, particularly as it is a major cycle route.
Addressed to: Leicester Campaign Cycling Group; Leicester City Council
AI-generated concerns summaryThe coroner noted difficulties in accurately locating the incident due to inaccurate GPS information and a call handler lacking local knowledge. Concerns were raised about inadequate systems for cross-boundary call transfers and dispatch between different ambulance services.
Addressed to: Yorkshire Ambulance Service
AI-generated concerns summaryThe coroner raised concerns about a bridge being the site of two suicides, noting the ease with which its railings can be mounted. The report questions whether additional protection could be implemented to minimise recurrence.
Addressed to: Sussex Police; West Sussex County Council
AI-generated concerns summaryThe coroner noted that the East of England Ambulance Service NHS Trust should consider introducing training, similar to the EMAS Paramedic Pathfinder Programme, to help paramedics identify suitable patients for community treatment versus hospital transfer.
Addressed to: East of England Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified inadequate radio logging practices, including reliance on handwritten logs and missing FIRESNET logs. Concerns were also raised about the lack of secure digital recording capability for encrypted radio signals.
Addressed to: Minister of State for the Armed Forces
AI-generated concerns summaryThe coroner identified that a subsided section of road was substandard and dangerous, requiring immediate repair and appropriate warning signage with an advisory speed limit. Further, dangerous posts at the roadside necessitated the erection of an Armco barrier.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryUnsatisfactory safe discharge and inconsistent Early Warning Score (EWS) recording and communication were noted. The coroner also highlighted a lack of clear ECG guidelines for acute breathlessness and the extreme risk of absent senior medical review.
Addressed to: Doncaster and Bassetlaw Hospitals NHS Foundation Trust