Browse 6,493 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner raised concerns about a disengaged seat belt that led to a passenger being unrestrained and sustaining a neck fracture. The absence of a seat belt alarm meant carers were not alerted to the disengagement.
Addressed to: Royal Society for the Prevention of Accidents
AI-generated concerns summaryThe coroner noted delays in diagnosis, issues with incomplete blood test reporting, and medication prescribed before test results were known. Concerns also included an insufficient threshold for flagging critical blood-calcium levels, inadequate record-keeping, and apparent gaps in patient escalation to intensive care.
Addressed to: Department of Health and Social Care; Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the current driver's license renewal process for individuals over 70 focuses on sight and hearing, without a specific requirement for doctors to assess mental fitness to drive.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner suggested improvements to the layout of the Co-operative car park access way, noting it is regularly used by pedestrians and vehicles. Possible enhancements included tactile paving, extending road markings, or a central island.
Addressed to: Casualty Reduction Team
AI-generated concerns summaryThe coroner asked the housing provider to consider installing domestic sprinkler systems in special accommodation, noting that their provision would have made the death far less likely.
Addressed to: Whitefriars Housing
AI-generated concerns summaryThe coroner noted psychiatric staff acquiescing to patient requests not to contact families, especially when patients lack insight and staff may lack training to assess capacity. This lack of family contact can isolate vulnerable patients, increase their risk, and decisions regarding family contact may not be reviewed often enough.
Addressed to: Hafod Community Mental Health Team; NHS England; Windsor and Maidenhead Community Mental Health Team; Wokingham Community Mental Health Team
AI-generated concerns summaryThe coroner noted repeated difficulties in obtaining a specific medication (Clonidine) for a patient, caused by prescription errors and a lack of communication between the GP surgery and the hospital. These issues led to delays that put the patient at risk of withdrawal symptoms.
Addressed to: Portsmouth Hospitals NHS Trust; Waterside Medical Centre
AI-generated concerns summaryStaff assisting an unwell train passenger lacked basic first aid training, potentially delaying recognition that his airway had become partially occluded.
Addressed to: Association of Train Operating Companies; Department for Transport
AI-generated concerns summaryThe coroner regarded the death as potentially avoidable and endorsed recommendations from a Trust investigation report. The report emphasised that the Trust must seriously address the issues detailed within its own recommendations.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the reliance on patient-reported weight for medication dosage when direct weighing was not possible, and the lack of processes for obtaining and communicating relevant family medical history to medical staff.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryA patient presenting with a head injury was streamed to a GP clinic instead of the Emergency Department, contrary to medical advice that all suspected head injuries should be referred to the A&E Team.
Addressed to: Bedfordshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted insufficient procedures for checking wheelchairs before use, resulting in some being used with missing or faulty footplates. There was also a lack of independent wheelchair checks and doctors were misinformed about a patient's injury despite staff awareness.
Addressed to: Heathers Nursing Home
AI-generated concerns summaryThe coroner raised concerns about a general practitioner's suboptimal asthma management, citing insufficient respiratory assessment and monitoring. Additionally, the prescription of Diazepam for anxiety was noted as poor treatment, especially with sleep apnoea or respiratory distress.
Addressed to: Basildon Road Surgery; NHS England
AI-generated concerns summaryPsychiatric staff did not properly assess the patient's risk of self-harm or communicate vulnerabilities, and there were failures in follow-up due to unreliable communication. Previous recommendations regarding risk assessment and follow-up had not been completed eighteen months later.
Addressed to: South London and Maudsley Trust
AI-generated concerns summaryThe coroner noted a lack of clear best practice guidance regarding the use of gastro-intestinal protection when prescribing NSAIDs to children with sickle cell disease, despite expert evidence of perforation risk.
Addressed to: Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryConcerns were raised about a gap between a safety barrier and the back of a vehicle that allowed a fall. The report also notes that passenger health and mobility risk assessments relied solely on voluntary information rather than a formal process.
Addressed to: Bedford Borough Council
AI-generated concerns summaryThe coroner noted a lack of a clear 'back-up' process to ensure patients lacking capacity attend follow-up appointments, particularly when family members are not included in correspondence.
Addressed to: Northern Medical Centre; Whittington Hospital NHS Trust
AI-generated concerns summaryThe coroner noted the rapid spread of fire from a Hotpoint fridge freezer's insulation material significantly reduced escape opportunities. Concerns were raised about the risk of further deaths if manufacturers do not review the use of highly flammable insulation in kitchen equipment.
Addressed to: Indesit Company
AI-generated concerns summaryThe coroner identifies gaps in ensuring staff awareness of policy updates and comprehensive driving regulations for multi-lane highways. Concerns also include the need to expand supervising paramedic roles to include driving, ensure ongoing driver training, and improve communication within and between ambulance services.
Addressed to: Association of Ambulance Chief Executives; London Ambulance Service
AI-generated concerns summaryConcerns were raised about steep, poorly illuminated steps lacking a handrail, making them difficult to negotiate. Additionally, a low riverside wall opposite the steps was noted as an insufficient safety barrier.
Addressed to: Durham County Council