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 noted insufficient ambulance availability leading to delayed patient attendance, and excessive handover delays at hospitals preventing timely release of ambulance crews.
Addressed to: DEPARTMENT OF HEALTH; NHS ENGLAND; NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
AI-generated concerns summaryA recommended grab rail was not provided, and carers failed to escalate a fall or refer for further assessment of the patient's mobility or equipment needs. Additionally, care documentation did not reference the risk of falling from stairs.
Addressed to: Doncaster Council
AI-generated concerns summaryThe coroner noted gaps in mental health information sharing between services, leading to inaccurate records and insufficient escalation of care. Concerns were also raised about unclear operational policies and the delegation of risk assessment.
Addressed to: Essex Partnership University NHS Trust; Mid & South Essex NHS Trust
AI-generated concerns summaryThe coroner noted that all lanes open motorways lack intermediate stopping areas between those spaced every 1.6 miles, and these motorways are also not monitored.
Addressed to: Highways England
AI-generated concerns summaryThe coroner noted a history of collisions at a site known as “suicide hill” and highlighted witness suggestions for improved signage to alert road users to the hill and sharp turn, particularly in poor visibility.
Addressed to: ERYC Highways Department
AI-generated concerns summaryThe coroner noted concerns that removing compulsory direct observed training for neonatal intubation competency in paediatric specialist training could increase reliance on non-resident consultants and reduce future general paediatricians' experience in complex neonatal resuscitation.
Addressed to: Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner raises concerns regarding the easy accessibility of electric motors and parts used to convert pedal bicycles into high-powered, throttle-controlled scooters. These vehicles can achieve high speeds and rapid acceleration, posing dangers to both the rider and other members of the public.
Addressed to: Department for Transport; Welsh Government
AI-generated concerns summaryThe coroner raised concerns about the lack of a formal, documented handover system for pressure sore information between hospital and Neighbourhood Teams, hindering community teams from verifying patient conditions upon discharge. The report noted that proposed solutions were not yet sufficiently detailed or concluded.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust; Worcestershire Acute Hospitals Trust
AI-generated concerns summaryThe coroner noted the absence of risk assessments, safe working practices, adequate training, and suitable PPE for new tasks. Concerns also included unsafe equipment, insufficient supervision, and a workplace culture that did not address employee safety issues.
Addressed to: Ward Bros (Malton) Ltd
AI-generated concerns summaryThe coroner noted limited internal review of Mr Tompkins' death, particularly regarding procedures performed simultaneously, and that the Trust did not appear to consider NatSSIPS2 standards during the procedures or in its subsequent review.
Addressed to: Royal Free Hospital
AI-generated concerns summaryThe coroner notes a lack of national and local guidance for cross-titration of psychiatric medication and the discontinuation of electronic patient observation on psychiatric wards, raising concerns about varied practice and insufficient monitoring.
Addressed to: Royal College of Psychiatrists
AI-generated concerns summaryThe coroner raises concerns about prison staff failing to manage cell observation panels safely and in accordance with policy, noting a culture of delayed cell entry when panels are obscured. This practice, which risks lives, persists despite previous incidents and multiple staff notices.
Addressed to: HMP Lowdham Grange
AI-generated concerns summaryConcerns were raised regarding inadequate recruitment, retention, and training of prison and healthcare staff, leading to understaffing, overwhelming workloads, and a deterioration in prisoner safety and healthcare provision at HMP Lowdham Grange. There were also noted deficiencies in basic training for prison officers.
Addressed to: HMPPS; NHS England; Nottinghamshire Healthcare NHS Foundation Trust; Serco; Sodexo
AI-generated concerns summaryConcerns were raised regarding nurses at Northampton General Hospital incorrectly administering insulin to patients after meals, despite specialist advice and training. This practice was noted to be ongoing and not an isolated incident, potentially reducing medication effectiveness.
Addressed to: NORTHAMPTON GENERAL HOSPITAL NHS TRUST
AI-generated concerns summaryThe coroner identified a lack of national guidelines and a standard operating procedure for bone marrow aspirate and trephine biopsy procedures, and the absence of a database to record these procedures and their outcomes.
Addressed to: British Society for Haematology (BSH); National Institute for Health and Care Excellence (NICE); NHS England
AI-generated concerns summaryThe coroner identified a lengthy and unclear DVLA licence renewal process with inconsistent information and poor communication channels. The report also noted an absence of a vulnerable customer protocol and discrepancies between verbal driving permission and online licence status, which hindered employment.
Addressed to: Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner raised concerns regarding the prominence of signage and absence of road markings on the approach to the hump back bridge on the B5012 Cannock Road.
Addressed to: Staffordshire Highways
AI-generated concerns summaryThe coroner noted the junction of St Johns Road and the A43 Northamptonshire is difficult to manoeuvre, raising concerns that without changes, further accidents or fatalities are likely.
Addressed to: National Highways
AI-generated concerns summaryAn out-of-hours GP lacked training on BARDOC pathways and patient record access, which led to an incorrect call closure. The coroner also identified a general inability for health professionals to access patient data across different NHS IT systems.
Addressed to: BARDOC; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that imported products are sold nationally without warnings regarding their highly poisonous and toxic nature, which poses a risk to life.
Addressed to: Department for Environment, Food and Rural Affairs; Minister for Employment Rights, Competition and Markets; Office for Product Safety and Standards