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 summaryAmbulance response times for acute medical incidents are severely impacted by patient handover delays at acute hospitals, which prevents crews from returning to service.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a potential misunderstanding regarding the scope of UCLH's dietetic service and suggested clarifying on its website or in correspondence that it is not a mental health service and does not treat eating disorders.
Addressed to: University College London Hospitals NHS Trust
AI-generated concerns summaryInsufficient radiologist staffing at the hospital, especially during weekends, contributed to a subtle abnormality being missed on a CT scan. Staffing levels remain below Royal College of Radiology guidelines, posing a risk of future deaths.
Addressed to: Department of Health and Social Care; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner notes the absence of a 24/7 thrombectomy service in Lancashire and a lack of understanding among non-stroke specialist clinicians regarding its availability. Additionally, there is no regional mutual aid for thrombectomy services.
Addressed to: Lancashire Teaching Hospitals; NHS England; Northern Care Alliance NHS Foundation Trust
AI-generated concerns summaryThe report highlights a mound of earth on a motorway's central reservation creates a continuing hazard, risking loss of vehicle control and death for users who strike it.
Addressed to: National Highways
AI-generated concerns summaryThe coroner identified concerns that current regulations do not require aircraft manufacturers to provide crucial system and flight-testing data to suppliers of critical components. This information is needed for suppliers to fully assess component performance and reliability, ensuring they can safely meet in-service operational demands before certification.
Addressed to: Civil Aviation Authority; European Union Aviation Safety Authority
AI-generated concerns summaryThe coroner notes a lack of diabetes training and awareness among Prison Service staff regarding hypoglycaemic or hyperglycaemic attacks. This, combined with limited healthcare operating hours, could delay vital care for diabetic prisoners.
Addressed to: Department of Health and Social Care; HMPPS
AI-generated concerns summaryThe coroner expressed concerns about an uncontrolled pedestrian crossing on the A4 Great West Road lacking pedestrian lights, making safe crossing difficult. Implementation of planned safety redesigns is uncertain, with potential delays until late 2026.
Addressed to: Department for Transport; London Borough of Hounslow; Transport for London
AI-generated concerns summaryThe rationale for not detaining Callum in hospital was not recorded in the notes. Additionally, his decision not to involve his mother in his discharge was not adequately explored, with noted gaps in record keeping.
Addressed to: Cornwall Council
AI-generated concerns summaryThe coroner identified concerns regarding safety planning during discharge, specifically that clinicians did not sufficiently explore the individual's refusal to involve their mother in care, contrary to professional guidance.
Addressed to: NHS Cornwall and Isles of Scilly ICB
AI-generated concerns summaryThe coroner noted a prolonged disagreement between a housing provider and the Council over responsibility for housing a cuckooed tenant, and conflicting internal Council views on homelessness applications for tenants with social tenancies.
Addressed to: Cornwall Council
AI-generated concerns summarySanctuary Housing did not adequately determine if a vulnerable tenant was being cuckooed or who caused significant property damage. This led to an inappropriate possession notice and highlighted a lack of clear process for responding to cuckooing concerns.
Addressed to: Sanctuary Housing
AI-generated concerns summaryThe coroner noted the significant disparity between 26,000 families on Cornwall's housing register and only 1,000 properties available annually. This shortage limits the Council's ability to house homeless individuals and contributed to the deceased's mental state.
Addressed to: Ministry for Housing Communities and Local Government
AI-generated concerns summaryThe coroner identified gaps in guidance for sellers of a reportable poison, noting it inadequately addresses sales for self-harm and leads to misidentification of suspicious purchases. Vendors often lacked awareness of this misuse, while online platforms facilitate access to information on methods.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about vendors' unawareness of their products' misuse and the public's access to websites promoting methods to end life.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and that their websites were used to promote suicide methods.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified gaps in guidance under the Poisons Act 1972 for online sellers regarding substances used for self-harm, noting insufficient training and reporting mechanisms for small purchases. The report also highlights vendors' unawareness of misuse and the ease of accessing information on how to acquire and use poisons for …
Addressed to: Home Office
AI-generated concerns summaryGuidance for sellers of a reportable poison lacks specific advice for identifying self-harm purchases, leading to misinterpretation of small quantity sales as legitimate. Home Office guidance overlooks deliberate misuse, while online platforms promote obtaining poisons for self-harm.
Addressed to: Home Office
AI-generated concerns summaryThe coroner highlighted insufficient guidance for online sellers of certain reportable poisons regarding potential misuse for self-harm, noting that small quantity purchases are often misidentified as legitimate rather than evaluated for risk.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified gaps in guidance for sellers of a reportable poison, particularly regarding the sale of small quantities for self-harm, which are often presumed legitimate. Vendors are frequently unaware their products are promoted on websites aiding self-harm, leading to insufficient reporting of suspicious transactions.
Addressed to: Home Office