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 summaryPrisoners in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists for assessing swallowing difficulties. This lack impacts their medical management, including recommendations for fluid, food intake, and soft diets.
Addressed to: Serco
AI-generated concerns summaryThe absence of a barrier at the end of the footpath, combined with a narrow pavement and restricted visibility from tall fencing and shrubbery, creates a hazard for children emerging onto the road.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner identified that seasonal agricultural workers often lack awareness of how to access UK GP services, emergency numbers, and their entitlement to free care, leading some to obtain prescription medicines from their home countries.
Addressed to: East Lincolnshire Clinical Commissioning Group; South Lincolnshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted concerns regarding the quality of care by the district nursing team, specifically a lack of baseline assessments, insufficient involvement of tissue viability specialists, and the absence of basic equipment like thermometers. Additionally, poor record-keeping and limited communication with the GP were identified.
Addressed to: Pennine Care Trust
AI-generated concerns summaryThe coroner raised concerns about the hospital's recording and verification of patient addresses during transfers, which led to confusion about the correct GP practice and incorrect forwarding of medical information for warfarin monitoring. This issue could affect other patients.
Addressed to: Stafford Hospital
AI-generated concerns summaryThe coroner identified that paramedic training and guidelines prohibit gentle internal manipulation or traction during childbirth, which may hinder effective assistance in cases of dystocia. Concerns were raised that amending these guidelines could reduce the risk of injury during birth.
Addressed to: JRCALC; East Midlands Ambulance Service; South Central Ambulance Service
AI-generated concerns summaryThe coroner noted that pedestrians on the central reservation lacked a clear view of traffic lights and there were no dedicated pedestrian signals or control buttons, making it difficult to determine when it was safe to cross both lanes.
Addressed to: Harrow Council; Traffic and Harrows Network Management Compartment
AI-generated concerns summaryThe coroner noted a co-worker had not received specific training for working at height. Generic risk assessment forms and method statements were available but not routinely used by employees.
Addressed to: Carrington Doors
AI-generated concerns summaryThe report raises concerns for Saga Homecare regarding the circumstances surrounding the death of an 84-year-old lady who had fallen while receiving daily home care.
Addressed to: Saga Homecare
AI-generated concerns summaryThe coroner noted recurrent deaths from vehicles leaving carriageways and entering rhynnes, often resulting in drowning, and suggested action to prevent future occurrences, despite the prohibitive cost of widespread barrier installation.
Addressed to: Somerset County Council; Taunton Couthy Hall; County Surveyor
AI-generated concerns summaryThe coroner raised concerns regarding road safety at the bend in the A19 at Owston, requesting consideration of specific measures to reduce road traffic-related injuries at this location.
Addressed to: Regeneration and Environment
AI-generated concerns summaryThe coroner noted that a falls risk assessment for a patient with a known high falls risk was not conducted within the anticipated 24 hours of arrival at a nursing home, due to it being a weekend and staffing pressures.
Addressed to: Fairlight Nursing Home
AI-generated concerns summaryThe coroner noted issues with recording medication dosage and early consideration of alcohol detoxification upon admission. Other concerns included delayed discontinuance of Tramadol, delayed shoulder x-ray, and unavailability of special nursing staff for a high-risk patient.
Addressed to: Western Sussex Hospitals NHS Trust