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 that pub environments present a higher risk of injuries requiring emergency treatment, and raised concerns about the lack of CPR training for staff, which limits their ability to provide lifesaving treatment.
Addressed to: JD Wetherspoon PLC
AI-generated concerns summaryThe coroner noted the need for a review of policies concerning the out-of-hours availability of Resuscitation Officers by the Resuscitation Council UK and NGH NHS Trust.
Addressed to: Northampton General Hospital Trust; Resuscitation Council UK
AI-generated concerns summaryThe coroner identified inconsistencies in understanding between hospital and community teams regarding post-discharge procedures and patient access points for complications. Concerns were also raised about the lack of documented patient advice on discharge and poor communication from the vascular ward regarding post-operative issues.
Addressed to: Gateshead Health NHS Foundation Trust; Newcastle Upon Tyne Hospitals NHS Foundation Trust
AI-generated concerns summaryThe D&D cell did not obtain critical information regarding the pilot or plane's capabilities, nor the weather at the diversion aerodrome. A lack of checklists and miscommunications limited the ability to provide adequate assistance to the pilot.
Addressed to: Civil Aviation Authority; Military Aviation Authority
AI-generated concerns summaryThe coroner highlighted the absence of British or European standards for lithium-ion e-bike batteries and chargers, which facilitates the sale of unsafe products and increases the risk of thermal runaway, fires, and deaths.
Addressed to: Product Safety and Standards
AI-generated concerns summaryThe coroner noted insufficient falls prevention for a high-risk patient due to bed placement and a single sensor mat. Concerns also involved the lack of written records for an incident investigation and the manager's inability to identify involved staff.
Addressed to: Care UK
AI-generated concerns summaryThe coroner noted insufficient staff training for complex hoarding cases, a lack of essential safety assessments, and the council's support procedures were inadequate, focusing on enforcement rather than tenant assistance, leaving vulnerable individuals without a clear forward plan.
Addressed to: Central and North West London Mental Health Trust; Forward Trust; Hillingdon Council
AI-generated concerns summaryThe coroner highlighted a lack of accurate data on under-18 festival attendees and no national oversight of drug-related casualties. Concerns included insufficient measures to deter illicit drugs and the need for better staff training to identify and assist vulnerable attendees.
Addressed to: Department for Culture, Media and Sport; Festival Republic; Home Office; Leeds City Council; West Yorkshire Police
AI-generated concerns summaryThe coroner noted concerns regarding the inadequacy of the risk assessment process, including a binary form that did not recommend actions and was not updated after significant events. There were also issues with staff familiarity with care plans and the system's inability to preserve historical care plan versions.
Addressed to: Globe Court Care Home
AI-generated concerns summaryThe coroner identified errors in medication prescribing and dispensing by a GP and pharmacist, along with a lack of the correct morphine strength option within the EMIS prescription system.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted concerns regarding the Crisis Team's achievement of the 4-hour assessment target and inconsistent completion of the mandated Triage Tool. Further issues included insufficient safeguarding referrals for children when warranted and a lack of assurance that crucial Safety Plans are completed in all cases.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryRecent suicidal ideation expressed by Mr. Harris during a police interview was not recorded on Person Escort Record and Suicide and Self-Harm Warning forms, raising concerns this could lead to future underestimation of risk.
Addressed to: Dyfed-Powys Police
AI-generated concerns summaryThe coroner noted that bed rail assessments were not integrated into the Welsh Nursing Care Record, raising concerns that these crucial assessments might be missed, potentially leading to future falls.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryConcerns included a lack of training for the independent hoist user and her main carer on safe usage and emergency procedures. Additionally, inspection reports were not shared between departments, potentially leading to incomplete safety assessments of the equipment.
Addressed to: Bureau Veritas UK Ltd; London Borough of Southwark; Medicine Healthcare products Regulatory Agency; Prism Medical UK Ltd
AI-generated concerns summaryThe coroner raised concerns that individuals not registered with an NHS GP in Milton Keynes may not receive clear direction on how to obtain out-of-hours and emergency mental health care, leading to gaps in assessment and treatment.
Addressed to: BLMK Integrated Care Board; North West London NHS Foundation Trust; Red House Surgery
AI-generated concerns summaryThe coroner noted a restricted view at the B1190 Tom Otter’s Lane junction with C267 Sand Lane, where drivers need to stop for safety, but the road signage only requires a 'give way'.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryThe coroner identifies a lack of awareness among clinicians that acute epiglottitis is increasingly found in adults, leading to its misdiagnosis as a sore throat. Education and training are needed to improve recognition and early treatment.
Addressed to: Association of Ambulance Chief Executives; Royal College of Emergency Medicine; Royal College of General Practitioners; Urgent Health UK
AI-generated concerns summaryConcerns at Hydon Hill Nursing Home included insufficient information sharing with healthcare providers, delayed antibiotic treatment, non-recognition of cardiac arrest, and incorrect DNAR reporting. The report suggests policy updates and staff training.
Addressed to: Leonard Cheshire
AI-generated concerns summaryThe coroner expressed concern that the railway line at Askam station remains readily accessible, including via nearby stiles, as Network Rail declined to implement recommended anti-trespass measures citing resource limitations and no prior trespass history.
Addressed to: National Rail Infrastructure Limited
AI-generated concerns summaryTees Esk and Wear Valleys NHS Foundation Trust routinely delays serious incident investigations, which may allow hazards to persist and compromise the quality of these investigations. This practice does not align with the nationally recognised 60-working day timeframe for completion.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust