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 the absence of industry standards or guidance for estate agents to warn tenants about property hazards like accessible but unsafe roofs. In this case, information about tenants on such a roof was not noted or followed up by the estate agent.
Addressed to: National Trading Standards; Network Agencies Estate Agents
AI-generated concerns summaryThe coroner identified that the GP practice did not follow the lower limb framework, failed to refer to tissue viability, or escalate concerns about a deteriorating wound. The practice also lacked adequate systems for internal investigation and timely review of patient safety incidents.
Addressed to: Meanwood Group Practice
AI-generated concerns summaryThe coroner noted concerns regarding repeated surgery cancellations due to insufficient theatre availability, despite reviews of patient prioritisation. The report indicates that the number of available theatres remains unchanged, posing a risk of similar incidents.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified extreme operational pressure on ambulance services, leading to unallocated 999 calls and delays, linked to inadequate social and community care. Ambulance staff resort to advising self-conveyance or arranging taxis when emergency ambulances are unavailable.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.
Addressed to: Care4U Healthcare
AI-generated concerns summaryThe coroner noted a lack of public appreciation for the life-threatening risks associated with storing lithium-ion batteries from e-bikes in domestic properties, identifying insufficient communication and media coverage on these dangers.
Addressed to: National Fire Chief’s Council; Office of Product Safety Standards
AI-generated concerns summaryThe coroner raises concerns about fire risks due to moisture ingress into condensate pumps, and highlights gaps in data sharing, analysis, and manufacturing standards related to white goods fires.
Addressed to: Association of Manufacturers of Domestic Electrical Appliances; British Standards Institute; Hotpoint UK Appliances Limited; National Fire Chief’s Council; North Yorkshire Council; Office of Product Safety Standards; Home Office
AI-generated concerns summaryThe coroner noted an absence of recorded mental health or medication reviews for the patient between April 2020 and February 2024, and was unable to confirm if reviews had occurred but were not recorded, or if they had not taken place.
Addressed to: Dearne Valley Group Practice
AI-generated concerns summaryThe coroner noted inadequate record keeping regarding a peritoneal defect during surgery, which was not documented and other staff were unaware of. Concerns were also raised about the Trust's investigation, which failed to address this defect as the root cause of death.
Addressed to: Royal Orthopaedic Hospital NHS Foundation Trust
AI-generated concerns summaryTwo mental health teams did not conduct holistic risk formulations as per NICE guidance, and a clinical lead used a simplistic assessment. The Trust also lacks audits for risk assessments of patients referred to but not accepted by its mental health team.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryInsufficient staff training at HMP Eastwood Park regarding neurodiversity, ACCT procedures, and constant supervision was noted. Issues were also identified with healthcare staff training on updating care plans and a ligature point in Residential Unit 3.
Addressed to: Avon and Wiltshire Mental Health Partnership Trust; HMP Eastwood Park; Ministry of Justice; Practice Plus Group
AI-generated concerns summaryThe London Borough of Newham's social work and NRPF teams exhibited unprofessional behaviour, poor management, inadequate supervision, and insufficient record-keeping, risking sub-optimal care. The National Police Air Service also discounted a relevant heat signature during a search.
Addressed to: Department of Health and Social Care; London Borough of Newham; National Police Air Service; Social Work England
AI-generated concerns summaryThe coroner notes insufficient public transport links to Bournemouth Airport and a lack of safe pedestrian access, leading people to walk on busy roads without dedicated footpaths or crossing facilities, particularly along Parley Lane and Hurn Court Lane.
Addressed to: BCP Council; Bournemouth International Airport Ltd
AI-generated concerns summaryHospital discharge notes are not uniform across trusts, risking essential patient information not being available to treating clinicians in new settings and potentially delaying life-saving care.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted insufficient professional curiosity among clinicians, a lack of escalation when a patient's condition declined, and the absence of consultant involvement when indicated. Concerns were also raised about the lack of detail in clinical notes.
Addressed to: Royal Free London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Mr. Lawlor had only two keywork sessions in four months at HMP Elmley due to staff shortages, and that insufficient key-working could impact risk reduction for other prisoners.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner identified insufficient road signage to help drivers navigate a busy roundabout, particularly when markings are obscured by traffic. Additionally, there was inappropriate signage to inform cyclists about an available dual-use path and Toucan Crossing.
Addressed to: Hull City Council; National Highways
AI-generated concerns summaryThe coroner raised concerns regarding the Army's Vulnerability Risk Management process, including a lack of consideration for 'checking in' on soldiers at risk of self-harm. Other issues included non-mandatory suicide prevention training and inadequate information sharing.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted outstanding mitigation measures at a train station, including a lack of Samaritan signs and low fencing, with no confirmation of implementation. Concerns were also raised about the absence of specific guidance and training for mental health staff on managing service users who decline visits or meetings.
Addressed to: Berkshire Healthcare NHS Foundation Trust; British Transport Police; South Western Railways
AI-generated concerns summaryDecisions regarding Mrs Tellam's transfer between hospitals did not give sufficient weight to continuity of clinical care, leading to her being taken to Derriford Hospital rather than the orthopaedic team at Royal Cornwall Hospital who had recently operated on her for post-operative concerns.
Addressed to: Cornwall Partnership NHS Foundation Trust; Royal Cornwall Hospital NHS Trust; University Hospitals Plymouth NHS Trust