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 noted open access to the M56 motorway via steps, damaged boundary fencing nearby, and an absence of warning signs for the public, particularly given a children's play area in the vicinity.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted visitors to the Critical Care Ward were not consistently washing their hands, identifying a lack of measures to ensure this essential infection control precaution was followed.
Addressed to: Salford Royal Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clear advance signage indicating a slip road is 'no entry' and that temporary signs at the exit are prone to being knocked over. These issues have led to repeated instances of drivers mistakenly using the slip road.
Addressed to: A-One+; Cleveland Police Roads Policing Unit
AI-generated concerns summaryA change in Linda Rignall's condition, recorded on the NEWS Observation chart, was not reported to a doctor on the Acute Medical Unit nor was she assessed.
Addressed to: Royal Sussex County Hospital
Addressed to: HMP Pentonville
AI-generated concerns summaryThe coroner notes that access to the roofs of commercial units under railway arches has not been blocked, specifically from the Lycamobile kiosk and Sonny Kebab and Chicken shop.
Addressed to: Network Rail
AI-generated concerns summaryAn error in transferring medication details between Mars sheets led to Mrs Gatt not receiving her anti-psychotic medication, with the coroner noting a lack of formal training for nursing staff on these procedures.
Addressed to: Shire Lodge Nursing Home
AI-generated concerns summaryThe coroner noted concerns regarding a hoist sling's tendency to "bag" at the sides, which could allow a patient to fall if they leaned to one side during transfer.
Addressed to: Sunrise Medical Limited; Faversham Nursing Home
AI-generated concerns summaryThe coroner raised concerns about detention staff's insufficient awareness and training on mental health indicators, alongside inadequate communication of observations to healthcare staff. Additionally, medical practitioners lacked necessary knowledge, routine medical visits for segregated detainees were inadequate, and a comprehensive clinical record system was absent.
Addressed to: GEOAmey; Nestor Primecare; Serco; Home Office; Practice Plc
AI-generated concerns summaryThe coroner raised concerns regarding obstructed visibility for drivers approaching the level crossing due to a rise, barrier controls, and the road angle. There were also concerns about the level crossing telephone being positioned 8 metres beyond the pedestrian stop line.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner raised concerns about the Trust providing inaccurate and misleading investigation reports, which contained erroneous findings and incorrect root causes. There was also a failure to communicate the report's shortcomings or correct recognised errors before the inquest.
Addressed to: University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner highlighted issues with discharge follow-up mechanisms for patients transferring areas, specifically regarding continuity of support, and questioned the appropriateness of follow-up letters in cases of non-contact.
Addressed to: Community Mental Health Recovery Services
AI-generated concerns summaryThe coroner noted difficulties with accurate and consistent recording of vital signs and integrating the Paediatric Early Warning Scoring system into GP medical records. Additionally, the GP computer system does not alert clinicians to complete relevant clinical parameters, such as a croup severity score, after a diagnostic code is entered.
Addressed to: Health Education England; NHS England; Royal College of Emergency Medicine; Royal College of Paediatrics and Child Health
AI-generated concerns summaryInadequate staffing at Waxham House impacted timely personal care and dignity, alongside insufficient protocols for chasing district nurses. St Mary's Hospital lacked systems for recording and reporting safeguarding alerts for inpatients.
Addressed to: Care Quality Commission; Isle of Wight Adult Safeguarding Team; St Mary’s Hospital; Waxham House Residential Care Home
AI-generated concerns summaryThe coroner noted a junior doctor's lack of awareness regarding prior pain relief from the ambulance service and hospital policies for overnight discharge. Concerns were also raised about the absence of senior clinicians for second opinions late at night.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted training needs in communication following patient handover, a lack of falls risk assessment and low bed provision for Mr. Page, and a need to review nursing staff levels.
Addressed to: Withybush General Hospital
AI-generated concerns summaryThe coroner noted no referral to a GP for a falls risk assessment upon admission, despite Mrs. Roberts' declining condition. Additionally, her care plan and falls risk were not reassessed or updated after her return from hospital following a first fall.
Addressed to: Manor Park Residential Home
AI-generated concerns summaryThe coroner raised concerns about the positioning of a light switch, near the emergency call switch, which may have been out of reach for a frail patient, and noted the absence of a risk assessment for the patient's room placement.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryInconsistent advice was given to patients discharged post-surgery regarding the risks of venous thromboembolism and urgent clinical signs, both orally and in writing.
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryThe coroner raises concerns about the absence of protocols for supporting staff during care provider closures, insufficient training on staff attitudes and team leader supervision, and inadequate management of communication channels after a closure.
Addressed to: Care Quality Commission; Surrey County Council