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 that staff directly involved with Craig Steadman were unaware of investigation findings and recommendations following his death in custody, indicating a lack of process for disseminating learning to relevant prison and healthcare staff.
Addressed to: Chief Coroners Office; HMP Winchester; Practice Plus Group
AI-generated concerns summaryConcerns relate to the DVT risk assessment tool potentially overlooking patients with specific risk factors but normal mobility, and those on psychiatric units. Additionally, clinicians' lack of awareness that observations can normalise as a clot passes risks clots being overlooked.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted that care agency responders did not identify a fractured neck of femur after a fall and relied excessively on the patient's self-assessment. There are concerns that current training may be insufficient to identify such injuries or effectively communicate diagnostic limitations to ambulance services.
Addressed to: Medequip UK
AI-generated concerns summaryThe coroner noted a lack of understanding by Priory staff regarding available NHS community discharge services and a general lack of clarity across all services on whether private-paying patients could be referred to NHS discharge packages.
Addressed to: Department of Health and Social Care; Priory Group
AI-generated concerns summaryThe coroner noted that applicants for shotgun certificates can obtain medication online without their GP's knowledge, risking incomplete disclosure of medical history to licensing authorities. Concerns were also raised about how authorities can obtain full disclosure of an applicant's history of coercive controlling behaviour.
Addressed to: Department of Health and Social Care; National Police Chiefs’ Council; Surrey Police; General Practitioners Committee; Home Office
AI-generated concerns summaryA disparity in understanding and expectations between two medical teams regarding the operation of the Patient Pass system caused uncertainty and confusion, which could place patients at risk.
Addressed to: Northern Care Alliance NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient clinical guidance on radiation-induced sarcoma and first-line investigations for breast implant patients, noting the 5-year surveillance period is shorter than the condition's 10-year latency. There were also concerns that a hospital's 2-week post-aspiration review protocol was not followed.
Addressed to: Ashford and St Peter’s Hospitals NHS Foundation Trust; Department of Health & Social Care; Royal College of Nursing; Royal College of Radiologists
AI-generated concerns summaryThe coroner identified instances where agency staff did not read care plans, affecting the safety of residents.
Addressed to: Monarch Health Care C/O Heeley Bank Care Home
AI-generated concerns summaryThe coroner noted unacceptably long waiting times for Child and Adolescent Mental Health Services (CAMHS) assessment and treatment, which have significantly increased. Concerns were also raised about the effectiveness of the 'Keeping in Touch' team due to insufficient resources to manage the growing waiting list.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryPrison staff misunderstood the need for meaningful ACCT observations, treating them as superficial checks, and did not share risk-pertinent information. The coroner also noted failures in securing and retaining accurate documentary evidence after the death.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe canal railing offered no protection for a small child, and Peabody Housing Association did not risk assess it or act on resident complaints about its safety. The initial planning application for the development also did not consider the barrier's safety.
Addressed to: Islington Borough Council; Mayor of London; Ministry of Housing, Communities and Local Government; Peabody Trust
AI-generated concerns summaryThe coroner noted insufficient support for the individual's health and abstinence, with concerns that referral for residential care should have been earlier. Additionally, there were long and increasing waiting times for residential rehabilitation placements.
Addressed to: Department of Health and Social Care; Ministry of Housing, Communities & Local Governments; NHS England; SE London Integrated Care Board
AI-generated concerns summaryThe coroner noted concerns regarding the design of amateur-built balloons, particularly the lack of Civil Aviation Authority (CAA) guidance on their design, testing, and inspection. There is also no CAA regulation or guidance for safe oversight of competition balloon flying in the UK.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryConcerns were raised about the quality and documentation of care at Westmorland Court, including unreliable resident notes, a nurse's actions during resuscitation, and the absence of a defibrillator.
Addressed to: Care Quality Commission; Nursing and Midwifery Council; Westmorland Court Care Home
AI-generated concerns summaryA site investigation identified issues with road markings, signage, and lighting, leading to recommendations for Durham County Council Technical Services to address these.
Addressed to: Durham County Council
AI-generated concerns summaryThe ambulance crew and paramedic were unaware of the deceased's multi-agency 'familiar faces plan', which held crucial information, due to data limitations on their electronic devices. The coroner is concerned this vital information is not easily accessible to first responders in emergency situations.
Addressed to: North East Ambulance Service
AI-generated concerns summaryConcerns were raised that roadwork crews continue to urinate between LGV rear axles, a practice risking fatal injuries from vehicle movement. The coroner noted a lack of wider industry awareness or safety notices about this ongoing risk.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner identified insufficient regulation of home-to-school transport for Special Educational Needs children, citing problems such as transport crew not understanding patient safety plans, missing home visits, lack of mandatory first aid training, and an absence of comprehensive operator inspections.
Addressed to: Department for Education; Local Government Association; Traffic Commissioner for West of England
AI-generated concerns summaryThe coroner identified that organisations and care settings should consult the Fire Service for advice on mitigating fire risks from vulnerable individuals who smoke, suggesting measures like metal wastepaper bins and fire-retardant materials.
Addressed to: Royal Society for the Prevention of Accidents
AI-generated concerns summaryThe coroner identified gaps in prison policy for recognising childbirth as a mental health risk factor and issues with ACCT process robustness and staff training. Concerns also included the negative mental health impact of extended cell confinement for prisoners, exacerbated by a shortage of gym instructors.
Addressed to: His Majesty’s Prison and Probation Service; Ministry of Justice