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 concerns that drivers with medical conditions can provide inaccurate information to independent GPs for HGV licence renewals, as these GPs cannot verify medical history. It suggests requiring reports from the driver's own GP or allowing independent GPs access to records.
Addressed to: Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner noted insufficient timely notification and formal review for ERCP procedure complications. There were also gaps in regular, comprehensible communication with next of kin about management plans, and a lack of clarity regarding named Surgical Consultant cover during unexpected leave.
Addressed to: East Suffolk and North Essex Foundation Trust
AI-generated concerns summaryThe coroner noted easy access to the M56 motorway's hard shoulder from a pedestrian walkway via a ramp-like structure and a metal ladder. There is no fencing to prevent access from the hard shoulder onto the motorway along this stretch of the eastbound carriageway.
Addressed to: National Highways
AI-generated concerns summaryThe coroner notes delays in the delivery of essential medical equipment by NRS Healthcare, along with the provision of defective or incorrect replacement parts, which hindered optimal patient care. Concerns were also raised about ongoing service issues from NRS Healthcare, acknowledged by NHS England and the Trust.
Addressed to: NHS England; NRS Healthcare
AI-generated concerns summaryThe coroner noted a lack of coordination and communication between primary and secondary care providers, specifically due to electronic record systems (SystmOne and EMIS) not being easily accessible to each other, and limited practical interaction between GP practices and GPimhs.
Addressed to: Esher Green Surgery; Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Mr McGowan, living with Autism and complex mental health needs, encountered cultural, structural, and systemic barriers to receiving physical health treatment. These barriers meant his bacterial endocarditis was only partially treated, leading to his death.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns were raised regarding the device's Instructions for Use, which omitted a critical error message and the significance of disappearing control icons. Additionally, the unique alarm function was unknown to users, and manufacturer maintenance lacked a wear-and-tear identification process.
Addressed to: LivaNova UK Limited
AI-generated concerns summaryThe coroner identified a lack of specialist mental health nurses in West Yorkshire Police's Occupational Health Unit and no post-death investigation into care quality. Concerns also relate to unclear procedures for officers disclosing suicidal thoughts and the impact of the Police Constable Degree Apprenticeship.
Addressed to: College of Policing; National Police Chiefs’ Council; West Yorkshire Police
AI-generated concerns summaryThe coroner raises concerns about the absence of legal restrictions on newly qualified drivers regarding the number of young passengers they can carry, which may increase collision risk. This prompts a request to review current provisions to prevent future similar deaths.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identifies an absence of legal restrictions on newly qualified drivers regarding the number and age of passengers they can carry, noting the increased risk of collisions for young drivers with similar-aged passengers.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted that some mobility scooters may be manufactured without an independent secondary braking system and older models without this feature are still in use. There is concern for the safety implications for riders and the public, leading to a recommendation to review guidelines for fitting secondary braking systems …
Addressed to: Department for Transport; Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe report highlights concerns regarding a faulty emergency exit door and a lack of staff awareness about its operation, prompting a request for confirmation that corrective actions are ongoing.
Addressed to: Victoria Residential Home
AI-generated concerns summaryThe coroner noted a lack of guidance for prophylactic antibiotics in immunocompromised patients and inadequate mechanisms for evidencing trainee experience, obtaining consent, or identifying and sharing individual patient risk factors.
Addressed to: Birmingham Women’s and Children’s NHS Foundation Trust; Department of Health & Social Care
AI-generated concerns summaryThe coroner noted the absence of written records for risk assessments by the AMHT, which could lead to inadequate information sharing and hinder future investigations into deaths.
Addressed to: Oxford Health NHS Foundation Trust
AI-generated concerns summaryInformation from parents of autistic children, provided via a Trust helpline, is not consistently fed back to weekly audit meetings, potentially hindering the identification of deteriorating conditions and timely adjustments to clinical priorities.
Addressed to: Humber Teaching NHS Foundation Trust
AI-generated concerns summaryRestrictions prevent pharmacists from dispensing a different strength of medication even when the same dose can be given, which delayed a child's antibiotic treatment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of recorded and shared information across agencies, which prevented an accurate risk assessment. There were also delays in ED triage and police were not notified when the individual left the emergency department.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the easy and open availability of Ketamine to students, which was being dealt from or by individuals with access to student halls of residence.
Addressed to: Fresh Student Living; University of Arts London
AI-generated concerns summaryThe coroner raised concerns that the 30 mph speed limit on A361 North Bar Street may be too high, given the road's characteristics, pedestrian volume, and obscured visibility of a crossing. A slower speed might have mitigated the collision.
Addressed to: Oxfordshire County Council
AI-generated concerns summaryThe coroner identified that the 40 mph speed limit on a section of the A694 is unsafe, given its residential location, bends, junctions, and history of collisions involving pedal cycles, pedestrians, and motor vehicles.
Addressed to: Gateshead Council