Browse 6,470 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 raised concerns that thin surface road treatments, in their early life, can reduce friction for vehicles, particularly motorcycles, even in dry conditions. There is no guidance for warning signage, potentially leading to unpredictable vehicle behavior.
Addressed to: Association of Directors of Environment, Economy, Planning & Transport; Department for Transport; Road Surface Treatments Association
AI-generated concerns summaryThe coroner noted that current NICE guidelines on Induction of Labour and Intrapartum Care do not explicitly address analgesia levels and supervision during labour, which was a factor in a mother becoming comatose.
Addressed to: NICE
AI-generated concerns summaryThe coroner identified the lack of a formal documented system for risk stratification and a written Standard Operating Procedure for lead extraction. This resulted in unclear planning for cardiac surgical team support and insufficient clarity on timely surgical attendance.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe HMP Birmingham secreted item policy lacks clear guidance for situations where an item has been ingested without its packaging. There is also no equivalent level of monitoring for prisoners previously under constant supervision when transferred to the prison regime.
Addressed to: HM Prison & Probation Service
AI-generated concerns summaryConcerns are raised regarding gaps in shotgun licence regulation, specifically the lack of obligation for holders to notify police about moving or storing shotguns at different properties. The less stringent nature of shotgun regulation compared to firearms poses a risk.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe pre-day surgery assessment system does not directly require questions about haematological family history and fails to record negative answers to questions regarding a patient's own haematological history.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted concerns about the unrestricted availability of high-purity sodium nitrite in lethal quantities and the absence of a central monitoring system for poisoning incidents. There are insufficient regulations on its import and sale, with quantities exceeding legitimate uses.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryAn Operational Support Grade did not demonstrate familiarity with HMPPS Medical Emergency Response Codes policy regarding summoning emergency assistance and calling an ambulance for an unconscious prisoner. This could compromise optimum reaction to prisoner health emergencies.
Addressed to: HM Prison & Probation Service; HMP Woodhill; Ministry of Justice
AI-generated concerns summaryMental health screening assessment results from one region are not always immediately available in another due to incompatible IT systems, potentially leading to incomplete subsequent assessments and incorrect referral prioritisation.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified insufficient repositioning of patients requiring it, particularly those with chest infections, and inadequate recording of patient positions, with documented gaps up to 27 hours. This poses a risk of future deaths.
Addressed to: Frimley Health NHS Foundation Trust
AI-generated concerns summaryConcerns include significant delays in forced entry during welfare checks due to sub-optimal information gathering and classification, a lack of clarity on legal entry powers, and the impact of the 'Right Care, Right Person' policy on initial emergency response.
Addressed to: College Of Policing; Greater Manchester Police
AI-generated concerns summaryThe coroner identified gaps in the training and guidance for firearms officers concerning the timing of 'armed police' announcements, specific tactical options like 'hard stops,' and the application of lethal force principles. There were also concerns about the effectiveness of post-incident review and learning.
Addressed to: College of Policing; West Midlands Police
AI-generated concerns summaryThe Medical Priority Dispatch System (MPDS) used by the London Ambulance Service lacks specific determinants for heart attack under its Chest Pain protocol, meaning these calls do not receive a Category 1 response. This rigidity may increase the risk of death from cardiac arrest due to delayed ambulance arrival.
Addressed to: Emergency Call Prioritisation Advisory Group; London Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified insufficient paramedic training and knowledge regarding vascular emergencies, particularly atypical presentations of Abdominal Aortic Aneurysm (AAA) rupture, noting a lack of recent medical education on subtle signs.
Addressed to: Association of Ambulance Chief Executives
AI-generated concerns summaryThe coroner noted a failure to apply Detention Centre Rule 35 for a detainee with suicidal intentions due to a mismatch in understanding between healthcare and the Home Office. Concerns also arose regarding an inappropriate 'closed' visit which prevented physical contact and private conversation.
Addressed to: Home Office; Mitie; NHS England
AI-generated concerns summaryThe coroner noted inconsistent provision of ME services and diagnosis nationally, alongside insufficient research into the condition. Concerns were also raised regarding a lack of professional understanding of ME and unclear implementation of recent NICE guidance.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the hospital had not fully implemented measures to address accepted failings, specifically lacking standard operating procedures for managing worsening renal unit patients. This led to clinician uncertainty regarding appropriate patient pathways, increasing risks of delays and treatment errors.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner noted Ann's severe malnutrition and declining frailty were not investigated despite repeated requests, which meant she was unsuitable for life-saving treatment. Additionally, no internal investigations were conducted by her GP or the hospital trust to learn from these circumstances.
Addressed to: East Kent University Hospitals Foundation Trust; Manor Clinic Folkestone Kent
AI-generated concerns summaryThe coroner noted that GP appointment times are often insufficient for holistic review of chronic disease patients, and templates for chronic disease reviews lack a dedicated section for mental health assessment.
Addressed to: Department of Health & Social Care; Queen Mary’s University of London
AI-generated concerns summaryThe coroner identified a lack of clear responsibility for patient care across multiple health services and communication gaps between agencies. Concerns also included night duty staffing capacity and the overall system complexity that impeded urgent care provision.
Addressed to: Cumbria Health Limited; Department of Health and Social Care; North West Ambulance Service NHS Trust; SSP Health Ltd