Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted the area was a known flood risk and that insufficient gully maintenance might have contributed to surface water on the road. Concerns were also raised about the use of only a temporary flood warning sign in a persistently flood-prone location.
Addressed to: Hampshire County Council; National Highways
AI-generated concerns summaryThe coroner raises concerns that the Crisis Resolution and Home Treatment Team does not have access to GP records, noting this information could be vital for future patient assessments.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted minimal training for private ambulance staff regarding patients under the influence of illicit substances at a music event. There was also a lack of clarity regarding responsibility for pre-alerting the hospital, and the private ambulance lacked equipment found in NHS ambulances.
Addressed to: Kent Central Ambulance Service
AI-generated concerns summaryThe coroner noted concerns regarding a liquid washing detergent's packaging, which resembled a milk carton, and its easy-access screw top. This design poses a risk of accidental ingestion for vulnerable adults with dementia due to potential confusion.
Addressed to: Department of Environment Food and Rural Affairs; Royal Society for Prevention of Accidents
AI-generated concerns summaryThe coroner noted that significant delays in emergency ambulance dispatch were due to prolonged handover times at the emergency departments of Aneurin Bevan University Health Board hospitals, predominantly the Grange University Hospital.
Addressed to: Aneurin Bevan University Health Board; Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe supported living provider's policy did not allow staff to remove excess medication for safeguarding a resident experiencing a mental health crisis, as it required the resident's consent.
Addressed to: Home Group Limited
AI-generated concerns summaryThe care home's emergency response was delayed and disorganised, with staff failing to promptly sound an alarm or call 999. Ineffective first aid and delayed CPR occurred due to a misunderstanding of resuscitation orders.
Addressed to: Aspray House Nursing Home
AI-generated concerns summaryThe coroner noted misleading information regarding the level of supervision offered and a lack of formal induction periods and support plan reviews for residents in the care setting.
Addressed to: Alexandra Homes Ltd
AI-generated concerns summaryThe coroner raises concerns about delays in a criminal investigation, which mean an identified suspect is not subject to conditional bail, driving disqualification, or remand. This absence of measures is identified as creating a risk of further fatal harm.
Addressed to: London Metropolitan Police
AI-generated concerns summaryThe coroner raised concerns regarding plastic barriers on the A660 Leeds Road that offered no resistance to a vehicle after a collision, allowing it to leave the road. The report notes the ongoing presence of similar inadequate barriers in other sections of the road.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner identified concerns regarding staffing levels affecting mental health assessments and key worker schemes, alongside communication gaps between prison and healthcare staff on information sharing and system access. Also noted were challenges with prison officer checks and staff training.
Addressed to: HMPPS; Minister of State for Prisons; Ministry of Justice/HMP Wandsworth; Oxleas NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of shared understanding between police and the ambulance service regarding the applicable local policy and working standards for managing s.136 detentions, posing a risk to vulnerable individuals.
Addressed to: East Midlands Ambulance Service; Nottingham and Nottinghamshire Police
AI-generated concerns summaryThe coroner raises concerns about an unexplained gap in the safety barrier on the M1 southbound. This gap increases the risk of vehicles leaving the carriageway at high speed and colliding with trees, which could lead to serious injury or death.
Addressed to: National Highways Agency
AI-generated concerns summaryConcerns involve formally disseminating learning across St George's and the NHS about malrotation diagnosis, especially ultrasound limitations and upper GI contrast study thresholds. The report also highlights a need for enhanced safety netting advice for abdominal conditions.
Addressed to: NHS England; St George’s University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that delayed hospital discharges due to a shortage of social care placements lead to high falls risk patients remaining in acute settings. This places challenges on nursing resources and reduces bed availability for other patients.
Addressed to: Greater Manchester Integrated Care; Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns that most hospital Trusts lack processes to document external calls from midwives, which can lead to insufficient continuity and escalation of care, particularly regarding parental concerns.
Addressed to: NHS England; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted a lack of adjustments for a patient with learning disabilities and autism, despite existing policies and training. Concerns remain regarding the auditing of the impact and compliance of these policies, as identified needs were not consistently acted upon by clinicians.
Addressed to: Calderdale and Huddersfield NHS Foundation Trust; CQC North; NHS England
AI-generated concerns summaryThe coroner noted GPs had a superficial understanding of regulatory requirements and practicalities for patients with Learning Disabilities and Autism, leading to inadequate adjustments and poor management of the Learning Disabilities Register. Concerns were also raised about the failure to properly record numeric observations and undertake a rigorous internal review …
Addressed to: CQC North; Dalton Surgery; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the availability of home rehydration services for elderly patients, noting that such provision could prevent hospital admissions and align with patient and family preferences.
Addressed to: Central London Community Healthcare NHS Trust; Mountfield Surgery
AI-generated concerns summaryThe coroner identified that no falls prevention equipment was implemented despite recommendations and concerns, with evidence of a reluctance to provide resources for it. There was also an absence of DoLS assessments for residents, including the deceased, who lacked mental capacity.
Addressed to: Care Quality Commission; Durham County Council; Howlish Hall Care Home; Williams and Spenceley Limited