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 identifies gaps in the current licensing system for drivers over 70, as it lacks mandatory medical checks or assessments and relies solely on self-declaration of fitness to drive.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner identified insufficient consideration of legal powers and persuasive steps when a patient detained under the Mental Health Act regularly refused medical treatment, along with insufficient action when the patient declined food over a prolonged period.
Addressed to: Priory Group
AI-generated concerns summaryThe coroner expressed concern regarding a vulnerable young adult illicitly obtaining and using a veterinary-only licensed substance for a suicidal purpose. This identifies a potential emerging risk, prompting reports to veterinary bodies to consider preventive measures.
Addressed to: Royal College of Veterinary Surgeons; Veterinary Medicines Directorate
AI-generated concerns summaryThe coroner noted divergent expectations between clinicians and radiologists regarding communicating specific scan preferences for pulmonary emboli investigations, along with a lack of clarity in the scan request process. It is unclear whether the hospital has fully considered standardising scan types.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryThe coroner noted issues with the DWP's process for making large payments to vulnerable adults, specifically the lack of robust systems to assess an individual's ability to manage such sums and the absence of detailed records for related conversations.
Addressed to: Department of Work and Pensions
AI-generated concerns summaryThe coroner noted that patient observations at Manor House Residential Home were sometimes not carried out every two hours as required, with instances of late observations recorded in January and February 2024.
Addressed to: Manor House Care Home
AI-generated concerns summaryThe coroner identified that established NICE guidelines and the local health and social care policy for supporting children in crisis were not applied in the Emergency Department, resulting in a missed opportunity for early mental health intervention for a young person who had self-harmed.
Addressed to: Suffolk and North East Essex Integrated Care Board; West Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies insufficient patient awareness of Olanzapine depot injection risks and the necessity of post-injection vital sign checks. Concerns also include challenges in ensuring observations in busy psychiatric wards and procedural gaps in medication approval processes.
Addressed to: North London Mental Health Partnership
AI-generated concerns summaryThe coroner raised concerns regarding the need for a uniform licensing framework for high-speed RIB experience rides, encompassing crewing levels, craft standards, and risk assessments. There were also concerns about revising standards for forward visibility with passengers and improving seat and handrail design for RIBs.
Addressed to: Associated British Ports; Bay Boats Limited; British Marine; British Ports Association; British Standards Institution; Department for Transport; Maritime and Coastguard Agency; Red Bay Boats LTD; Royal Yachting Association; UK Harbour Master’s Association; UK Major Ports Group
AI-generated concerns summaryDoctors did not follow the policy for treating hypokalaemia, failing to conduct daily U&E monitoring and administering further intravenous potassium without prior checks. The coroner notes a broader pattern of insufficient electrolyte monitoring by the Trust's doctors.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified gaps in protocols for assigning the correct medical specialism for biopsy procedures and noted the lack of a multi-disciplinary meeting to coordinate care, which resulted in delays and insufficient collaboration between teams.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that James Cook University Hospital utilizes fragmented and unintegrated record-keeping and prescribing systems, including both paper and electronic, across different wards and departments.
Addressed to: South Tees Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies industry-wide concerns about insufficient measures enabling persons who fall into marinas unwitnessed to get out or raise an alarm. Additionally, the Gold Anchor Award scheme's evaluation criteria do not adequately prioritise safety.
Addressed to: Yacht Harbour Association Ltd
AI-generated concerns summaryThe surgery's correspondence triage did not identify reported excessive fentanyl use, failing to trigger a medication review. Additionally, the surgery lacked specific policies or procedures to flag or review concerns regarding fentanyl abuse.
Addressed to: Brinnington Surgery
AI-generated concerns summaryThe coroner raises concerns about the absence of a requirement for section 10 exempt entities to report adverse event findings to the MHRA, other Trusts, or the wider industry. This lack of clear and mandatory reporting hinders wider learning and risk assessment for improving medication provision to vulnerable patients.
Addressed to: Care Quality Commission; Department of Health and Social Care; Medicines, and Healthcare Products Regulatory Agency; NHS England
AI-generated concerns summaryThe coroner raised concerns about the lack of adequate controls preventing the misuse of potentially lethal drugs by veterinary surgeons. The deceased easily obtained a Schedule 3 Controlled Drug without verification or scrutiny from former employers.
Addressed to: Royal College of Veterinary Surgeons; Veterinary Medicines Directorate
AI-generated concerns summaryThe coroner raises concerns about the ready availability of detailed online guides providing instructions for individuals to end their lives, noting that these are easily accessible through search engines and often lack age verification.
Addressed to: Department for Culture, Media and Sport; OFCOM
AI-generated concerns summaryThe coroner noted severe ambulance response delays due to a chronic lack of available ambulances and staff, with demand consistently outstripping resources. Handover delays at hospitals were identified as a substantial root cause, exacerbated by national issues in recruitment, retention, and social care.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a concerning practice of social ostracism, often referred to as 'cancel culture', among students, noting its potential for negative impacts on mental health and wellbeing. This 'self-policing' occurs without formal processes and can lead to isolation, raising a risk of future deaths.
Addressed to: Department for Education
AI-generated concerns summaryThe report highlights concerns about a taxi driver's understanding of their duty of care towards passengers and a lack of documented adherence to the taxi firm's protocol for contacting police in such circumstances.
Addressed to: Kingkabs