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 summaryConcerns were raised regarding the availability of ambulances for urgent inter-hospital transfers and emergency calls, alongside a lack of clarity in transfer categorisation. The ambulance service's action plan to address these issues was considered inadequate, lacking detail and measurable progress.
Addressed to: Department of Health and Social Care; East of England Ambulance service; NHS England
AI-generated concerns summaryThe coroner questioned whether the holiday home staircase met regulation standards for width, depth, and handrails at the time of a fall, and if any remedial work has been undertaken since.
Addressed to: Holme Farm
AI-generated concerns summaryBoatfolk Marinas Ltd's visual inspections did not identify a broken rescue chain, and such inspections alone may be insufficient to detect deterioration. North Somerset Council lacked a formal assessment to determine if a significant change in port use, which would trigger a risk assessment review, had taken place.
Addressed to: Boatfolk Marinas ltd; North Somerset Council
AI-generated concerns summaryConcerns were raised regarding the poor quality of acute physical healthcare in mental health settings, including failures to recognise deteriorating patients and delays in escalation for secondary care. The report notes a lack of adherence to the NEWS2 policy and confusion among staff regarding emergency medical call procedures.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the surgical mortality review did not consider the role of anticoagulation and suggested discharge planning should prompt consideration of ongoing anticoagulant prophylaxis for patients discharged without full mobility.
Addressed to: North Cumbria Integrated Care
AI-generated concerns summaryConcerns were raised about inconsistent understanding and recording of welfare checks for 'at risk' residents, leading to Mr Cork not being checked for over 24 hours. The recording system was inadequate, and staff missed an opportunity to properly assess his welfare.
Addressed to: Sapphire Independent Living
AI-generated concerns summaryA Trust template was not completed and no discharge letter was sent, impeding effective communication of the treatment plan. There were also concerns about delegating vital family information gathering to a very junior trainee.
Addressed to: West London NHS Trust
AI-generated concerns summaryThe coroner identified the absence of a required "Red clean" for a room previously occupied by a patient with MRSA before Mr. Hines' transfer, alongside the omission of routine MRSA screenings that should have occurred during his prolonged inpatient stay and prior to surgery.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns that Ms. Mitchell received 28 days of medication in 48 hours, despite a known overdose risk necessitating weekly GP prescriptions. There was no process for A&E staff to access her medical records to understand her dispensing regime.
Addressed to: Department of Health and Social Care; James Paget University Hospitals NHS Trust; NHS England; Rosedale Surgery Lowestoft
AI-generated concerns summaryThe coroner noted a lack of clear guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.
Addressed to: Association of Anaesthetists Great Britain and Ireland; Care Quality Commission; Chief Executive Health Education; Royal College of Anaesthetists
AI-generated concerns summaryThe coroner identified concerns regarding an online guide providing step-by-step instructions on how to end one's life, including methods to avoid coroner referral, and the availability of associated drugs. The guide has minimal age and ID checks before purchase, making it accessible to vulnerable individuals, despite being banned in some …
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the safety of a busy pedestrian crossing, highlighting a pedestrian's confusion about right of way and high usage by schoolchildren and older people. Without safety alterations, further accidents could occur, with the report suggesting consideration of traffic lights.
Addressed to: Area Transport and Highways; National Highways
AI-generated concerns summaryThe coroner raised concerns about the unsafe height and placement of electricity meters, particularly prepayment meters which require frequent access. The report notes a lack of industry standards for meter accessibility and insufficient records from the installing company regarding placement considerations.
Addressed to: Energy UK; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner noted a significant rise in fires from e-bikes/e-scooters, particularly due to inferior quality lithium-ion batteries and unsuitable chargers in conversion kits. Concerns were raised about the lack of specific safety standards for these products, leading to risks like mixing batteries with incorrect voltage chargers.
Addressed to: Product Safety and Standards
AI-generated concerns summaryThe coroner noted residual staffing shortages in the District Nursing Service at Tameside and Glossop Integrated Care and NHS Foundation Trust, which require a national change of approach to resolve.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a mental health assessment for a patient presenting with clear signs of self-harm and disclosed suicidal ideation, despite national guidelines recommending such assessment.
Addressed to: Frimley Health NHS Foundation Trust; Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an apparent anomaly in the Human Tissue Act, which prevents medical research establishments from accepting body donations when a coronial inquest is opened, even if a post-mortem examination is not required.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner notes a lack of clear understanding among agencies regarding the process for deciding on the removal of 1:1 patient observations, with disagreement between the Council and the care home on who holds responsibility. This indicates insufficient communication and understanding of the correct process between involved parties.
Addressed to: Birmingham City Council; Connaught House Care Home
AI-generated concerns summaryThe coroner noted prolonged prescribing of two dependency-forming drugs without a clear plan for dose reduction, despite the practice's own guidance highlighting the hazards of long-term opioid and gabapentinoid use for chronic pain.
Addressed to: Kirby Road Surgery
AI-generated concerns summaryThe coroner noted the absence of a system to provide alternative contact details when a mental health care coordinator is on sick leave, which prevented the family from obtaining assistance.
Addressed to: Navigo