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 regarding the need for improved communication training for nursing staff during emergencies and questioned whether dynamic assessments adequately consider the need for prisoner restraint. Additionally, the coroner noted the potential benefit of additional CCTV in common prison areas.
Addressed to: HMP Featherstone
AI-generated concerns summaryThe coroner identifies concerns regarding delays in Medtronic providing safety data, the inconsistent distribution of Field Safety Notices to NHS Trusts, and the insufficient analysis of medical devices during post-mortem examinations, which could hinder investigations.
Addressed to: Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; Medtronic; Royal College of Pathologists
AI-generated concerns summaryThe coroner noted confusion among professionals regarding the appropriate management of anti-social behaviour by individuals who are intoxicated or mentally unwell, suggesting a place of safety could have prevented Mr Long's death.
Addressed to: Cornwall Council
AI-generated concerns summaryConcerns included inadequate consultant on-call arrangements and adherence to national guidelines for sepsis treatment. The coroner also identified insufficient protocols and understanding regarding propofol infusions and Propofol Related Infusion Syndrome.
Addressed to: Association of Anaesthetists of Great Britain and Ireland (AAGBI); Basingstoke General Hospital; Frimley Park Hospital NHS Trust; Intensive Care Society; Medicines and Healthcare products Regulatory Agency; Royal College of Anaesthetists; Royal Surrey County Hospital
AI-generated concerns summaryThe coroner identified gaps in complete and accurate handover information between primary and secondary care, raising concerns about the prioritisation of children's cases in out-of-hours services. The report also noted a need to revisit national guidance on pre-hospital antibiotics for suspected meningitis and highlighted a fragmented approach to patient care …
Addressed to: Cwm Taf Health Board; National Institute for Health and Clinical Excellence; Prince Charles Hospital
AI-generated concerns summaryThe coroner raised concerns regarding insufficient measures to treat ice that had formed in the car park.
Addressed to: Pinner and District Community Association
AI-generated concerns summaryThe coroner identified gaps in information handover regarding outstanding investigations between shifts. Furthermore, there were significant delays in performing a chest X-ray (nearly 17 hours after order) and reviewing its results (over 24 hours later).
Addressed to: Plymouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns that medication was not secured and a large, potentially fatal, quantity was prescribed to someone apparently unaware of the dangers to others. The report notes the importance of assessing a person's ability to keep medication safe and documenting this decision.
Addressed to: Devon Clinical Commissioning Group; Drug and Alcohol Team Devon
AI-generated concerns summaryThe coroner raised concerns regarding the unrestricted sale of helium gas canisters to the public, noting they are standard sizes with sizable volumes and lack modified control valves. Easy availability of detailed online guidance for suicide by helium inhalation was also highlighted.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified that there are no current requirements to inspect roadside soft estate, such as developing trees, to ensure their protection needs are assessed against modern road restraint system standards within safety thresholds.
Addressed to: Department for Transport; Highways Agency
AI-generated concerns summaryThe coroner noted a significant risk for vulnerable bus passengers due to the lack of restraints or screen barriers for priority seating, which is not mandated by current regulations. Fitting seat belts to these seats would require significant modification and testing.
Addressed to: Backhouse Jones; Department for Transport; Fentons; Vehicle and Operator Services Agency
AI-generated concerns summaryThe coroner noted potential risks to railway crossing users due to reduced sighting lines from trackside vegetation, incorrectly positioned S.H.I boards, and tripping hazards on the crossing surface.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted failures in scheduling follow-up and urgent appointments, alongside missing documentation. Concerns were raised regarding the absence of systems to identify and correct these issues, and the timeliness of implementing an action plan.
Addressed to: City Hospitals Sunderland NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate good practice guidelines for assessments, resulting in incomplete and inconsistent evaluations of care needs. Concerns were raised about assessments failing to consider referrer reports or historical records, and insufficient investigation into available care.
Addressed to: Tower Hamlets Social Services
AI-generated concerns summaryThe Cardex system was not properly completed, with missing information on falls and family concerns. Incident reports were not followed up or updated, and a lack of cross-referencing contributed to delayed identification of injuries.
Addressed to: Salvation Army; Villa Adastra Care Home
AI-generated concerns summaryConcerns were raised regarding an inadequate CAMHS referral system and staffing levels, alongside an unrealistic workload for the school nurse service. The coroner also noted unverified qualifications and professional registration for the school counsellor.
Addressed to: Cumbria County Council; Cumbria Partnership NHS Foundation Trust
AI-generated concerns summaryCare staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Addressed to: HC-One
AI-generated concerns summaryThe coroner noted inconsistent criteria for requesting CT scans depending on the time of day or weekend, creating varying levels of care for patients "out of hours" and posing risks of future deaths.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified substantial delays in completing Serious Incident Reviews (SIRs) and sharing them with the coroner and family. This could hinder the timely dissemination of lessons learned and delay the coroner's own investigations, potentially limiting the effectiveness of PFD reports.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted an unmitigated tripping hazard at the location, which could lead to further falls and injuries, risking future deaths.
Addressed to: Denbighshire County Council