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 summaryConcerns were raised regarding pedestrian safety on the A1 trunk road near Haggerston Holiday Park, specifically noting the unlit crossing, restricted visibility for drivers, and the absence of warning signs or a central refuge.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner raised concerns about the presence of non-safety glass doors in rented properties where elderly people or children are occupants, and the lack of a system for replacing or making these doors safe.
Addressed to: South Kesteven District Council
AI-generated concerns summaryConcerns were raised regarding delays in surgical assessment and recognition of patient deterioration, along with an inappropriate unit transfer. The report also identified suboptimal clinical management, inadequate ward rounds, and a complete failure of the hospital's CT scanning service.
Addressed to: Brighton and Sussex University Hospitals
AI-generated concerns summaryThe coroner identified a lack of national guidance on the role of interpreters during labour, especially when interpreters are required in a theatre setting.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryPPO recommendations for high cholesterol and NICE-compliant investigations for loss of consciousness were not fully implemented. The coroner also noted inaccurate medical record entries by prison staff and doctors' lack of awareness regarding NICE guidelines for transient loss of consciousness.
Addressed to: Department of Health and Social Care; HMP-YOI Forrest Bank; Ministry of Justice; National Offender Management Service; Sodexo
AI-generated concerns summaryConcerns involved midwives' interpretation and escalation of abnormal CTG traces, particularly the inappropriate application of guidelines during a slow second stage of labour. The coroner also noted issues with CTG machines potentially displaying maternal heart rate as fetal heart rate due to an unknown multiplication factor, and the slow replacement …
Addressed to: Department of Health and Social Care; General Midwifery Council; Medicines and Health Regulatory Authority; National Institute for Clinical Excellence
AI-generated concerns summaryThe coroner noted an unsafe trek itinerary with an ascent rate double recommended limits for altitude sickness. The trek leader underestimated a trekker's severe illness and hesitated to access medical care, possibly due to cost.
Addressed to: ABTA - The Travel Association; Himalayan Encounters; Ministry of Culture, Tourism and Civil Aviation; Adventure Company; Association of Independent Tour Operators; Federation of Tour Operators
AI-generated concerns summaryThe London Ambulance Service did not automatically link specific risk factors, including age, fall height, and anti-clotting medication, to trigger an 8-minute emergency response for Mr Sutton.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the design of an access point to a service road parallel to the A4, where turning manoeuvres are difficult and potentially dangerous at a 70 mph speed limit.
Addressed to: West Berkshire Highways Authority
AI-generated concerns summaryThe coroner noted that the decommissioned road lighting system on a section of the M65 motorway meant drivers could not see debris and damaged vehicles in darkness, contributing to a series of further collisions.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted inadequate circulation of self-harm/suicide risk documents to healthcare and wing officers within the prison, alongside a failure to attach these to ACCT plans. There were also no clear procedures for logging that wing officers had reviewed relevant prisoner information.
Addressed to: HMPS; HMP Manchester
AI-generated concerns summaryThe coroner raises concerns that the junction's layout and slope create an optical illusion, making the stop sign and stop line visible only at close range, potentially causing driver confusion about right of way.
Addressed to: National Highways; Bradford Metropolitan District Council
AI-generated concerns summaryBeamish Museum had not conducted appropriate risk assessments to ensure the safety of volunteers and lacked direct or indirect managerial supervision of their activities.
Addressed to: Beamish Museum; HSE
AI-generated concerns summaryThe coroner noted concerns that a key HSE document, "People in Commercial Waste Containers" (Waste 25), may not be widely known within the waste industry, suggesting an alert system to improve awareness.
Addressed to: HSE's Waste and Recycling Sector Team
AI-generated concerns summaryThe coroner called for a review of procedures for seriously injured trauma patients at A&E, specifically regarding the summoning of on-call clinicians, CT scanning protocols, and reducing delays between patient presentation and surgery.
Addressed to: North Cumbria University Hospitals NHS Trust, The Cumberland Infirmary
AI-generated concerns summaryThe coroner identified a lack of assessment for a resident's suitability for a first-floor room, concerns about staffing levels and manager absence, and conflicting falls and manual handling risk assessments. Additionally, staircase furniture did not meet strength requirements.
Addressed to: Mymill Ltd. c/o Scraptoft Court Residential Care Home, Scraptoft Lane, Leicester LE5 2HT
AI-generated concerns summaryThe coroner noted a lack of clarity regarding the required supervision level for a speech and language therapy recommendation and insufficient access to external dysphagia awareness training for all staff.
Addressed to: Ashley Gardens Nursing Home
AI-generated concerns summaryThe coroner noted confusion among staff regarding patient-specific falls risks and classification. Inadequate post-fall management knowledge, insufficient dissemination of root cause analysis findings, and non-mandatory falls training were also identified.
Addressed to: The Whittington Hospital NHS Trust
AI-generated concerns summaryThe coroner noted that some staff did not ask Mr Abokar about suicidal thoughts due to a mistaken belief, contrary to training. There were also significant issues with resuscitation procedures, including an unconnected ambubag and oxygen not being switched on.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding St Stephens Gate Medical Practice's systems for practice nurses to access patient medical history, a lack of guidelines for nurses to refer patients to doctors, and no triggers for receptionists to book doctor's appointments, particularly for young children or babies.
Addressed to: St Stephens Gate Medical Practice