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 the scene of a fatal police shooting was not video recorded, which created difficulties with evidence and fostered public distrust. Concerns were also raised about the clarity of responsibility transfer from police to IPCC at a death scene.
Addressed to: Association of Chief Police Officers; Coroner's Society; Crown Prosecution Service; Home Office; Independent Police Complaints Commission; Metropolitan Police; National Crime Agency
AI-generated concerns summaryThe coroner identified inadequate clinician responses to failed home visits, including insufficient efforts to gain access or contact patients, and a lack of escalation. Concerns were also noted regarding the escalation policy and welfare check thresholds.
Addressed to: Leicester Partnership NHS Trust
AI-generated concerns summaryThe coroner notes that regulations for forward mirrors on lorries are not retrospective, meaning many vehicles lack this facility, and believes this contributes to continuing deaths in similar road circumstances.
Addressed to: Department for Transport
AI-generated concerns summaryThe rescue boat fall wire failed because the winch motor could easily overstress it. Concerns were raised that the LSA Code lacks requirements to assess the davit, winch, and fall wire as a system, and provides insufficient guidance on safety devices for these systems.
Addressed to: British Standards Institution; Department for Transport; Maritime and Coastguard Agency
AI-generated concerns summaryThe coroner noted that staff at the unit did not carry ligature cutters.
Addressed to: Care UK
AI-generated concerns summaryThere were insufficient ambulances available to cover the number of Red 1 and Red 2 calls during the early hours of 3rd October 2012.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified concerns regarding the swimming pool's dangerous profile and inadequate risk assessments for its features and non-swimmers. There was insufficient supervision, no staff trained in aquatic rescue, and unclear signage.
Addressed to: Chartered Institute of Environmental Health; Institute of Occupational Safety and Health
AI-generated concerns summaryThe coroner noted the swimming pool's inherently dangerous profile, inadequate risk assessments, and insufficient supervision without lifeguards or effective CCTV monitoring. Concerns also included unclear signage and a lack of staff trained in aquatic rescue techniques.
Addressed to: Chartered Institute of Environmental Health and Institute of Occupational Safety and Health
AI-generated concerns summaryThe coroner noted an inadequate needs assessment for Ross Boyd prior to his admission to The Willows, which resulted in an inappropriate placement for his care needs.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner noted the deceased was not wearing a HANS device, which is an inexpensive safety device that would likely have prevented or reduced the fatal head and neck injury sustained during a racing collision.
Addressed to: RAC Motorsports Association
AI-generated concerns summaryThere was no Specialist Community Perinatal Mental Health Service in Wirral, resulting in sub-optimal treatment. Additionally, the Liverpool City Region lacked a Mother and Baby in-patient Unit, leading to many distant referrals being declined.
Addressed to: Department of Health and Social Care; NHS England; Wirral Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted apparent failings in the care home's complaints procedure, which allowed staff to withhold concerns from senior management. There was also a lack of information for families on how to direct complaints to a more senior level within the organisation.
Addressed to: European Care
AI-generated concerns summaryLack of clear protocols for signposting individuals struggling to accept decisions and insufficient re-signposting to support agencies creates a risk that others may not receive necessary help.
Addressed to: Norfolk County Council
AI-generated concerns summaryThe coroner noted an inadequate response to external emergency services, with a lack of critical patient details and mislaid documentation. Concerns were also raised about the unavailability of ligature cutters in an emergency and insufficient detail in observation records.
Addressed to: Broudie Jackson Canter; DAC Beachcroft; Department of Health and Social Care; Greater Manchester West Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in treating a patient's clot risk, gaps in medical notes, and poor verbal communication during handovers between treating doctors. There was also a communication breakdown that delayed a CTPA scan.
Addressed to: St George’s Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted insufficient communication between psychiatric services and the general practitioner regarding a patient's Tramadol prescription. There is a need for open, two-way information sharing and access to documentation between primary and secondary care.
Addressed to: NHS England; NHS Sheffield Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted confusion in terminology and insufficient information exchange between hospital staff and the CRISIS team during out-of-hours calls. Additionally, significant delays prevented hospital and mental health documentation from reaching the GP.
Addressed to: Kent and Medway NHS and Social Care Partnership Trust; Maidstone and Tunbridge Wells NHS Trust
AI-generated concerns summaryThe coroner identified a missed opportunity by multiple medical and nursing teams to refer Mr O'Reilly to critical care, meaning he did not receive optimal care. Furthermore, observation records were missing for a significant period despite two-hourly monitoring being required.
Addressed to: Barts Health
AI-generated concerns summaryThe coroner noted that a street lamp near the collision site was unilluminated and another was obscured by overhanging foliage, which likely impacted the driver's visibility of the deceased.
Addressed to: Rhondda Cynon Taf County Borough Council
AI-generated concerns summaryThe coroner identified inadequate street lighting on Church Street, Leek, increasing risk for pedestrians, particularly elderly church users. Crossing facilities near St Edwards Church were also insufficient, exacerbated by the road's gradient and driver visibility challenges.
Addressed to: Staffordshire County Council