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 report highlights inadequate checks for airbag warning lights and module faults during MOT tests and routine car services. It also raises concerns about the risks posed by young, new drivers and suggests additional mitigation measures.
Addressed to: Department for Transport; Driver and Vehicle and Standards Agency; Motor Ombudsman
AI-generated concerns summaryThe coroner identified inadequate nursing records and handovers, alongside issues with doctors' task prioritisation and a failure by nursing staff to verbally request urgent medical reviews or seek urgent clinical assistance. Compliance with new procedural changes also lacked adequate assessment.
Addressed to: East Lancashire Teaching Hospitals
AI-generated concerns summaryThe coroner identified matters giving rise to concern, noting a risk of future deaths unless action is taken.
Addressed to: Medway Council
AI-generated concerns summaryThe coroner noted repeated missed opportunities to coordinate the deceased's care through multi-agency meetings and to make safeguarding referrals, despite escalating risks to self and others.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; South Tyneside Council
AI-generated concerns summaryPoor documentation of critical decisions concerning Mr Morton's sedation and mental capacity hampered an effective investigation into the clinical choices made. The coroner also noted a failure in governance to identify this as a serious incident, preventing proper review and remediation of practice.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that despite a risk assessment requiring lone workers to request checks, this did not occur. There was an identified opportunity to integrate a reminder about requesting checks into routine daily discussions with workers on site.
Addressed to: Canary Wharf Management Limited
AI-generated concerns summaryThe coroner identified that the design of BOC CD Oxygen cylinders, specifically the two-valve operation, is confusing for users in high-pressure situations, which can lead to delays in oxygen delivery. This issue persists despite staff training and reports made to the manufacturer and regulatory bodies.
Addressed to: BOC Limited
AI-generated concerns summaryThe immediate discharge summary lacked sufficient information for community care. Concerns included the absence of post-discharge nursing and GP follow-up for worsening conditions, and insufficient inquiry into private domiciliary care packages.
Addressed to: Care Quality Commission; City Healthcare Partnership Hull; Hull University Teaching Hospital; NHS England; Nursing and Midwifery Council; St Andrew’s Surgery Hull
AI-generated concerns summaryThe coroner identified a longstanding staff shortage in Cornwall and a lack of therapeutic alternatives like day hospitals or crisis units for patients with complex PTSD/EUPD in crisis. Additionally, there is a two-year waiting list for autism assessments, indicating demand significantly exceeds supply.
Addressed to: CIOS ICB; Department of Health and Social Care
AI-generated concerns summaryThe coroner highlighted delays in a work investigation and how easily allegations against the deceased became public among colleagues. There were also concerns that the distress caused by this should be a factor in accelerating the investigation's conclusion.
Addressed to: Queen Alexandra Hospital
AI-generated concerns summaryThe GP practice did not consistently conduct annual mental health and medication reviews for a patient with severe mental illness. A risk assessment was also absent during a mental health dip, with no follow-up after new medication.
Addressed to: Ashlea Medical Practice
AI-generated concerns summaryThe coroner noted a lack of clear guidance for highway inspectors regarding vegetation encroaching on pavements and raised concerns about the frequency of pavement inspections, especially on busy roads used by cyclists.
Addressed to: Surrey County Council
AI-generated concerns summaryThe coroner notes ongoing delays in North West Ambulance Service paramedics attending Category 2 calls, which remain outside target ranges due to ambulances being delayed in clearing Accident and Emergency departments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted delays in replacing feeding tubes due to limited radiology list availability for complex patients, leading to suboptimal nutrition. There is also a need to consider how best to maintain patient nutrition after tube dislodgments.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns about the impact of inadequate social housing on a palliative care patient's health and wellbeing, highlighting the lack of support services to assist with rehousing and the difficulties of the digital bidding process for alternative accommodation.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryA lack of knowledge and use of the "Professionals Checklist" by Adult Social Care practitioners meant individuals at risk of self-neglect were not assessed, and Multi-Agency Risk Management Meetings were not considered.
Addressed to: BCP Council
AI-generated concerns summaryThe coroner identified that staff were largely unfamiliar with the Mental Health Act Transportation Policy and lacked specific training on its provisions and associated risk assessment tools. The Trust had no system to ensure employees were trained on MHA transportation policies.
Addressed to: Herefordshire and Worcestershire Health and Care NHS Trust; West Midlands Ambulance Service
AI-generated concerns summaryThe coroner noted significant ambulance wait times for category 3 calls, often exceeding four hours, which impacted the patient's urgent need. There were also no specific sepsis trigger questions on the ambulance pathway to expedite response for suspected cases.
Addressed to: Greater Manchester Integrated Care; NHS England
AI-generated concerns summaryConcerns include errors in completing safeguarding forms, a failure to notify housing staff of a vulnerable patient's discharge despite requests, and an incorrect conflation of patient capacity with a lack of vulnerability.
Addressed to: North Cumbria Integrated Care
AI-generated concerns summaryInadequate licensing and deployment of door supervisors, including the use of unlicensed staff and inaccurate recording of operational numbers on SIA registers.
Addressed to: Addressees have not been indexed.