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 summaryThere was no framework for primary care staff to decide when an interpreter is required, and interpreters should be more readily available. Additionally, no system existed to flag relevant patient contexts to primary care staff.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns regarding significant deficiencies in the examination, assessment, and documentation of observations, Glasgow Coma Score, and haematoma details for babies and children in the Accident and Emergency department.
Addressed to: Doncaster and Bassetlaw NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a missed opportunity to provide suitable treatment and identified that new clinicians may not readily recognise sepsis deaths in children due to the rarity of such cases.
Addressed to: Plymouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified the absence of a documented regime for regular fetal heart auscultation after opiate administration to mothers. There were also concerns that further examinations and observations were not consistently undertaken following a change in the mother's condition.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryConcerns were raised that new procedures and protocols training is not mandatory for all relevant staff. Additionally, there are insufficient Acute Liaison Nurses, and no cover is in place for their absences.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner raised concerns about the extreme risks posed by the weir and salmon chute at the location, noting insufficient warning signage. The report asks for improved safety measures and clarification of responsibility for the site.
Addressed to: Environment Agency Headquarters
AI-generated concerns summaryThe process of proscribing MDAI (Gogaine), a "legal high" known to pose a fatal risk, particularly to individuals with cardiac problems, is moving slowly and its proscription should be accelerated.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted that Mr Andrews was discharged from hospital without his family being informed, leading to him arriving home alone with no immediate care in place, and subsequently falling.
Addressed to: Milton Keynes Hospital
AI-generated concerns summaryThe coroner questioned the feasibility of amending Riding Mill weir to incorporate a dedicated channel for canoes and kayaks, and constructing a safe upstream landing area with warnings for river exit during heavy flows.
Addressed to: Northumbria Water
AI-generated concerns summaryThe coroner noted a lack of focused checks on Mr Pether's limb viability and no re-evaluation of treatment options despite significant delays. The orthopaedic team also did not identify the source of infection even after his clinical condition deteriorated.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified a lack of national or local standards for the re-homing of stray dogs, specifically concerning the assessment of dog and applicant suitability, and required qualifications for assessors. There is also no independent verification of re-homing policies.
Addressed to: Department for Environment Food and Rural Affairs; Leicester City Council; Leicestershire Local Safeguarding Board; Ministry of Justice
AI-generated concerns summaryThe risk assessment tool relies on subjective practitioner assessment and lacks objective risk factor rating. This may hinder less experienced practitioners from identifying increased risk.
Addressed to: Not Listed
AI-generated concerns summaryThe coroner raised concerns regarding the 70 mph speed limit on the grid roads in Milton Keynes and pedestrian access to these fast roads, recommending a review of the speed limit.
Addressed to: Milton Keynes Council
AI-generated concerns summaryThe coroner raised concerns that the choking risks associated with raw jelly cubes are not sufficiently appreciated by childcare settings and parents. The report notes a lack of warnings on raw jelly packaging and insufficient supervision when used in play.
Addressed to: Department for Education; Food Standards Agency; Ofsted; Local Government Association
AI-generated concerns summaryThe coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
Addressed to: Betsi Cadwaladr University Health Boar
AI-generated concerns summaryThe coroner noted issues with the procedure for providing food to residents requiring special preparation and assistance, and a lack of appropriate ongoing professional development training for nursing staff.
Addressed to: Care Quality Commission; MPS Investments Ltd; Nesbit Law Group [Solicitors for the Clarkson family]
AI-generated concerns summaryThe coroner identified a lack of clear protocols in the West Midlands for managing sickle cell disease patients, noting that hospital staff had insufficient knowledge of crisis signs and treatment. This was compounded by a lack of funding to implement a regional 'hub and spoke' approach with consistent guidelines.
Addressed to: Birmingham and Solihull Clinical Commissioning Group; Commissioning groups; NHS England
AI-generated concerns summaryThe coroner noted the absence of detailed national guidance on antepartum CTG assessment, leading to difficulties in interpreting abnormalities and determining the urgency of intervention. Current reliance on intrapartum CTG guidance for antenatal cases is not evidence-based.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; Royal College of Gynaecologists and Obstetricians
AI-generated concerns summaryThe coroner identified a failure to follow the Trust's pressure ulcer policy, including inadequate incident reporting and risk identification. Further concerns related to insufficient record-keeping, confusion in patient care arrangements, and a lack of contingency for physiotherapy provision.
Addressed to: City Hospitals Sunderland NHS Foundation Trust
AI-generated concerns summaryThere was a significant difference in understanding among paramedics and management regarding the Trust's policy on compelling psychiatric patients to hospital, particularly concerning the use of physical coercion without police presence.
Addressed to: West Midlands Ambulance Trust