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 summaryInsufficient resources for the Speech and Language Therapy service at Royal Blackburn Hospital lead to delays in swallow assessments, increasing the risk of aspiration pneumonia for patients.
Addressed to: East Lancashire Healthcare NHS Trust
AI-generated concerns summaryReduced physiotherapy services on bank holidays and weekends pose an increased risk of post-operative complications for vulnerable patients.
Addressed to: St George’s Hospital
AI-generated concerns summaryThe coroner noted that six months after safety recommendations were made for a site with a previous drowning, no action had been taken. Public access continues despite closure, and signage prohibiting swimming is either absent or damaged.
Addressed to: Borough Council of King’s Lynn & West Norfolk; Norfolk County Council; Norfolk Police; Sibelco UK Ltd
AI-generated concerns summaryConcerns were raised about a delivery vehicle reversing from a car park rather than using a designated delivery area, and that signage for parking areas was not prominent or clear.
Addressed to: Northwood Square
AI-generated concerns summaryThe armed forces' code of practice for victims of crime does not specifically address victims of alleged serious sexual assault by another soldier. Additionally, staff implementing measures following a Suicide Vulnerability Risk Assessment received insufficient training and lacked regular follow-up training.
Addressed to: Armed Forces Minister; Provost Marshall (Army)
AI-generated concerns summaryThe coroner noted issues with the timely completion and transfer of police risk assessments, alongside a lack of shared understanding between SERCO and prison staff regarding accompanying documentation. Handover details on the Prisoner Escort Record (PER) were also not completed by prison staff.
Addressed to: HMP Wormwood Scrubs; Metropolitan Police; National Offender Management Service; Serco
AI-generated concerns summaryThe coroner noted the absence of a formal protocol for reporting and coordinating rescue operations related to life-threatening incidents in Portsmouth Harbour.
Addressed to: Queen’s Harbour Master Portsmouth
AI-generated concerns summaryConcerns were raised about the lack of a system to ensure compliance with PADI's requirement for up-to-date medical certificates for technical diving courses, noting that these requirements may be overlooked.
Addressed to: Professional Association of Diving Instructors
AI-generated concerns summaryThe coroner raised concerns regarding the incidence of anastomotic leaks following surgery, noting its relative rarity and the potential implication of technical error by the surgeon.
Addressed to: East Kent University Hospital
AI-generated concerns summaryThe coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Addressed to: Royal College of Physicians; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted that the company may not yet have ensured full compliance with relevant health and safety guidance, nor confirmed all drivers' awareness and understanding of it.
Addressed to: John Somerscales Ltd
AI-generated concerns summaryThe coroner noted that the care home's procedures for post-fall examination were insufficient, as staff did not perform neurological observations. Concerns were also raised regarding inaccurate information provided to paramedics about the resident's consciousness.
Addressed to: Rush Court Nursing Home
AI-generated concerns summaryThe coroner noted that Hope House lacked a clear and accessible policy or protocol regarding the administration and holding of medication by staff, which was not made known to prescribers or other relevant personnel.
Addressed to: 700 Club
AI-generated concerns summaryThe coroner identified that a rectal biopsy might have led to an earlier diagnosis of Hirschsprung's disease, and recommended reviews of NICE guidelines, hospital practices, and potential guidance from the Department of Health.
Addressed to: County Durham and Darlington NHS Trust; Department of Health and Social Care; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner raised concerns regarding the availability and regulation of chloroquine, noting the associated risk of misuse.
Addressed to: Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe railway crossing's warning light system, positioned before the gate, is not synchronised for multiple trains, allowing pedestrians to cross unaware of a second train. The coroner also noted the crossing type is unsuitable for a busy commuter and freight line.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted a continuing significant risk of strap misrouting impacting the safe operation of ejection seats, for which no design solution has been found. Concerns were also raised about the manufacturer's system for the urgent dissemination of safety-critical information to all end users.
Addressed to: Martin-Baker; the MOD
AI-generated concerns summaryConcerns were raised regarding a lack of early senior review for incorrect fluid charting, which contributed to fluid overload, and a failure to record doctor's visits and act on the patient's NEWS score.
Addressed to: Brighton and Sussex University Hospitals
AI-generated concerns summaryThe coroner raised concerns about a nurse's apparent lack of knowledge regarding the contraindication of administering insulin to a person with very low blood sugar levels.
Addressed to: Nursing and Midwifery Council
AI-generated concerns summaryThe coroner raises concerns about the ease with which individuals can acquire dangerous non-prescribed medication from websites, noting a lack of central government steps to screen and close down such sites.
Addressed to: Ministry of Justice