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 identified concerns regarding an unexplained delay in image transfer, the absence of a robust backup system, and insufficient data to investigate the issue. There was also a lack of clarity on the cause of an apparently erroneous scan report.
Addressed to: Radiology Reporting Online LLP; University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe trust's policy for responding to a patient collapse lacked clear guidance and did not require requesting a duty doctor. Nursing staff also did not act calmly or apply basic life support training effectively during the emergency response.
Addressed to: Barnet Enfield and Haringey Mental Health Trust; North London Forensic Service
AI-generated concerns summaryThe coroner noted the absence of signage to warn motorists about deer using the area as a game track.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe provided text indicates that concerns are set out in an enclosed letter and enclosures, but does not detail specific issues.
Addressed to: Italian Embassy
AI-generated concerns summaryThe coroner noted significant delays in Mr Martin's assessment, tests, and senior review in A&E, alongside concerns about the lack of appreciation for his symptoms and test results. Further issues included slow pharmacological treatment, unclear chest pain management protocols, and ineffective documentation.
Addressed to: St Peter’s and Ashford Hospitals
AI-generated concerns summaryThe coroner identified concerns regarding the safety of pedal cycle cleats and shoes supplied by Shimano Inc. and questioned the Department of Transport (UK) on regulatory oversight, risk assessment, and product warnings.
Addressed to: Department for Transport; Shimano Inc
AI-generated concerns summaryThe coroner noted insufficient and inaccurate information was given to participants and parents about the trip's risks and medical facilities. Concerns were also raised about inadequate risk assessments, lack of formal fitness assessments, and insufficient training for leaders on heatstroke and hyponatremia recognition and management.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner highlighted differences in how neonatal units assess a baby's stability and suitability for transfer, prompting a request to review the policy for approving inter-unit transfers.
Addressed to: Oxford University Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about a property in multiple occupation with a history of drug abuse, noting the potential for future drug-related deaths among inhabitants and asking for a review of the property's occupation.
Addressed to: Devon and Cornwall Police; Plymouth City Council
AI-generated concerns summaryThe coroner noted that the Personal Officer Scheme was not effectively implemented, ACCT checks were not conducted as prescribed, and prison officers lacked full conversancy and regular refresher training in first aid and CPR.
Addressed to: National Offender Management Service
AI-generated concerns summaryInsufficient availability of beds at the county's sole mental health crisis home meant a patient died while awaiting admission. The report notes the need for a review of facility provision.
Addressed to: NHS Cumbria Clinical Commissioning Group
AI-generated concerns summaryThe coroner notes that the lack of a universal emergency code system across the prison estate creates potential confusion and risks delaying assistance, particularly when staff transfer between prisons using different codes.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner identified insufficient warning signage for a road junction, as witnesses were unaware of existing indicators. The report suggests improving signage, potentially with double white lines or larger triangles, and reviewing the speed limit around junctions on the A356.
Addressed to: Dorset Highways Management
AI-generated concerns summaryThe coroner noted a regular hazard of water spilling onto the B5302, which contributed to a fatality and is exacerbated by freezing weather, posing a risk of further accidents if not addressed.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner noted a lack of awareness and clarity regarding the safe use and potentially harmful side-effects of Haz-Tab granules for urine spillages, compounded by limited teaching during staff induction and updates.
Addressed to: Guest Medical; Medicines and Healthcare products Regulatory Agency; St Peter’s and Ashford Hospitals
AI-generated concerns summaryThe coroner identified staff's lack of understanding regarding the patient leave policy and the role of support workers as escorts. Concerns were also raised about overdue risk assessments, insufficient information provided to families, and inconsistent visitor security on the ward.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that citalopram was given on repeat prescription contrary to guidelines, and questioned if GPs were aware of them. Concerns were also raised about ten-month waiting times for psychotherapy, making it an unviable alternative to medication.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in weekend cover for missing person coordinators and noted issues with officers' interpretation of the national "high risk" definition, which led to a delay in risk categorisation.
Addressed to: College of Policing
AI-generated concerns summaryHealthcare professionals lacked a good understanding of young people's evolving internet use and its impact on their wellbeing, highlighting a need for improved training and risk assessment refinement regarding digital lives.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns included inadequate discharge planning for Mr Slater, with no care plan, family involvement, or assessment for independent living. His flat was unsuitable, administrative processes were rushed, and there was a lack of structured support post-discharge.
Addressed to: Oldham Borough Council; Pennine Care NHS Foundation Trust