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 prison environment was not adapted to Mr Horrocks' daily living needs, and no care providers within the prison system accepted responsibility for assisting with his intimate personal care requirements.
Addressed to: Department of Health; National Offender Management Service; NHS England
AI-generated concerns summaryThe coroner raises concerns about the difficulty in identifying appliance manufacturers and models after severe fires, which hinders the detection of manufacturing defects and assessment of risks. There are also inconsistencies in how fire investigation findings are communicated to manufacturers and Trading Standards nationally.
Addressed to: Association of British Insurers; Association of Manufacturers Of Domestic Appliances; Beko Plc; British Standard's Institute; Chief Fire Officers Association; Department for Business, Innovation and Skills; Department of Communities and Local Government; British Retail Consortium; Chartered Society of Forensic Scientists; Institution of Fire Engineers; Trading Standards Institute; UK-AFI
AI-generated concerns summaryThe coroner identified confusion within the prison regarding the process for requesting an ambulance for life-threatening situations and the procedures for attending such prisoners. Concerns were also raised that the GP lead was unaware of her authority to verify death.
Addressed to: Care UK Limited
AI-generated concerns summaryThe coroner noted that appropriate signage needs to be easily seen at beach entrances and suggested it could include specific riptide hazard warnings, detailing when conditions are more dangerous.
Addressed to: Maritime and Coastguard Agency; North Devon District Council; Parkdeane Holidays; Royal National Lifeboat Institute
AI-generated concerns summaryThe coroner raised concerns about the difficulty in diagnosing atrial-oesophageal fistula, a rare but high-mortality risk of ablation procedures, due to its non-specific symptoms and a lack of awareness within the wider medical profession.
Addressed to: Department of Health and Social Care; Public Health England; The Heart Rhythm Society of the United Kingdom
AI-generated concerns summaryInadequate discharge planning for a patient with severe mental illness and new diabetes led to release into unsupported accommodation without a care package or medical follow-up. The coroner noted insufficient post-discharge support from Care Coordinators and gaps in staff training for complex cases.
Addressed to: South London and Maudsley trust
AI-generated concerns summaryInitial A&E paperwork was incomplete, as blood pressure and Glasgow Coma scales were not recorded on the front sheet.
Addressed to: Brighton and Sussex University Hospital NHS Trust; Royal Sussex County Hospital
AI-generated concerns summaryThe coroner noted concerns regarding the road's single broken white line and obscured view, suggesting consideration of double white lines. They also recommended replacing protruding "old style cats eyes" with slim-line versions to minimise future risk.
Addressed to: Powys Highways Department
AI-generated concerns summaryThe coroner identified that the RIO system lacked formal recording for both risk assessments and patient observation levels. This meant staff had limited knowledge of current risks, and robust care could not be audited.
Addressed to: Devon Partnership NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the lack of available hospital notes, poor communication among staff and with the patient's family, and inadequate patient monitoring. Further issues included consultant allocation and the process for initiating end-of-life care without sufficient family discussion.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about open pipe work in cells as potential ligature points for vulnerable prisoners. Additionally, there are concerns regarding insufficient multi-disciplinary input at ACCT reviews and a lack of accessible recording of significant medical events on non-medical records for prison staff.
Addressed to: HMP Downview; Lord Chancellor; Surrey and Borders Partnership NHS Foundation Trust; Virgin Care
AI-generated concerns summaryThe coroner noted damage to the liver from concentrated feeding fluid, potentially linked to the low-lying position of an umbilical venous catheter, a placement currently acceptable to most doctors. Concerns were raised about the risk of extravasation from UVCs and ongoing investigations into optimal catheter positioning.
Addressed to: NHS England; Norfolk and Norwich University Hospital NHS Foundation Trust; Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient ITU bed capacity due to nursing shortages, inadequate anaesthetic pre-assessment for high-risk patients relying solely on medical records, and the failure to secure a High Dependency Unit bed post-operatively for such a patient.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that specialist advice was not followed and a medication the patient had stopped was repeatedly prescribed. Concerns were raised about the system at Eltham Palace Surgery that allowed this to occur, and the lack of clarity on whether improvements have been made.
Addressed to: Eltham Palace Surgery
AI-generated concerns summaryThe coroner identifies that products not classified as toys may lack lockable battery compartments. Concerns also include the need for national guidance for medical professionals on managing button battery ingestion and the accessible display of batteries in retail settings.
Addressed to: Central Manchester University Hospitals NHS Foundation Trust; Department of Health and Social Care; Oldham Metropolitan Borough Council
AI-generated concerns summaryThe coroner questioned whether the pendant alarm provider adequately informs users, especially those at fire risk, about the option to link their alarm systems with fire alarms. The deceased's family was unaware of this additional facility.
Addressed to: Care Quality Commission; Welbeing
AI-generated concerns summaryThe coroner raised concerns regarding the inability to contact the Haematology Department and a lack of response from haematologists to messages seeking advice or patient review, identifying this as a risk to patient lives.
Addressed to: Bedford Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a lack of clear guidelines for managing intra-cerebral bleeds in patients on Warfarin, an absence of clarity on specialty responsibility for reversal decisions, and insufficient communication of relevant guidelines to staff.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe report identifies gaps in identifying and monitoring UK nationals convicted of murder abroad upon their return to the UK. These include a lack of retrospective notification of foreign convictions and no mechanism to alert local police when they reside in an area.
Addressed to: Ministry of Justice; Select Committee, Home Affairs; Home Office; Treasury Solicitors
AI-generated concerns summaryThe coroner noted concerns about the clarity of national guidance from the Royal College of Obstetricians and Gynaecologists regarding the administration of antibiotics to mothers for Group B Streptococcal Disease, particularly when induction of labour is involved.
Addressed to: Royal College of Obstetricians and Gynaecologists