Browse 6,458 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 summaryMechanical failure of Covidien Palindrome Chronic Dual Lumen Catheters, involving venous port detachment and blood loss, was identified in two incidents. The coroner raised concerns about a widespread vulnerability of this specific brand or batch, recommending a report to the MHRA.
Addressed to: Medicines and Healthcare Products Regulatory Agency; Medtronic Limited; University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner identified a lack of national policy or a designated lead for individuals receiving care from multiple agencies, leading to fragmented information sharing. There was also no simple mechanism across patient record systems to flag significant historical health and drug misuse issues.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted unclear communication and information flow between NWAS and CHOC, particularly regarding initial 999 call details and the procedure for returning calls to NWAS after failed patient contact.
Addressed to: Northwest Ambulance Service
AI-generated concerns summaryThe coroner noted that the NHS England 999 call pathway did not include a question to assess the immediacy of a stated plan to take one's own life, which may have affected the call handler's understanding of the case.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that the emergency cell bell system can be silenced by other prisoners, potentially delaying staff response to distress. Concerns were also raised about incomplete ACCT documentation due to some staff not valuing its completion, and persistent confusion among prison staff regarding 'Code Blue' emergency procedures.
Addressed to: HMP Swaleside
AI-generated concerns summaryThe coroner noted inconsistent attendance of healthcare team members, particularly the mental health team, at ACCT reviews, despite policy requirements. This poses an ongoing risk to vulnerable prisoners who rely on ACCT processes as a protective factor.
Addressed to: Oxlease NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about high levels of inexperienced prison officers across the wider prison estate, noting that insufficient numbers of experienced staff contribute to safety issues and insufficient communication within prisons.
Addressed to: Department for Prison, Probation and Reducing Reoffending
AI-generated concerns summaryThe coroner noted a lack of national guidance for frontline emergency services concerning complex, time-critical mental health situations. Non-specialist staff require clearer direction on appropriate actions when Mental Health Act provisions are not readily applicable.
Addressed to: Department for Women’s Health and Metal Health; Department of Health and Social Care; Home Office
AI-generated concerns summaryThe coroner noted the ready availability of illicit drugs in HMP Woodhill, inconsistent responses to intoxicated prisoners, and fragmented information-sharing across multiple systems. Concerns were also raised about blocked observation panels hindering welfare checks and inadequate management of prisoner vulnerabilities.
Addressed to: Central & North West London NHS Foundation Trust; Chief Inspector of Prisons; HMPPS; HMP Woodhill; Minister of State for Prisons; Prisons and Probation Ombudsman
AI-generated concerns summaryThe coroner expressed concern that drivers with significant medical conditions are not self-reporting to the DVLA, and doctors are not notifying the DVLA due to the legal onus being on licence holders, which is not robust enough for proper license review.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified risks of patients receiving incorrect or discontinued medication due to unclear and inaccurate administration records, insufficient information handover between community care providers, and a lack of standard practice for photographic medication records.
Addressed to: Coastal Homecare; Sussex Community NHS Foundation Trust
AI-generated concerns summaryRepeated instances of patients being granted ward leave without documented mental state examination or risk assessment were noted. Additionally, medical records featured poor documentation, including unflagged retrospective entries, which impacted subsequent investigations.
Addressed to: Rotherham Doncaster South Humber NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a process for doctors to notify private hospital management of practice limitations. There was also confusion among consultants and staff regarding emergency protocols and roles during major events requiring ambulance assistance or transfer to another centre.
Addressed to: Nuffield Health
AI-generated concerns summaryThe coroner noted a failure to re-triage and re-classify Mrs. Wiggett’s case after a second call reported increased pain, leading to delays in ambulance dispatch.
Addressed to: East of England Ambulance NHS Trust
AI-generated concerns summaryImportant information about a threat to take her own life was not passed to officers, leading to an insufficiently robust risk assessment that did not consider Natalie's vulnerability or accurately record her history.
Addressed to: Durham Police
AI-generated concerns summaryThe GP surgery did not prioritise an urgent prescription for seizure medication after information about the deceased running out was not fully conveyed. Concerns were also raised about nationwide difficulties for epilepsy patients in obtaining sufficient medication quantities and pharmacy processing delays.
Addressed to: Department of Health and Social Care; Sundon Medical Centre
AI-generated concerns summaryThe coroner raises concerns about the reliable operation of systems for early recognition and escalation of serious immunotherapy toxicity, noting that urgent oncology advice may be delayed and immunotherapy alert cards do not trigger a priority pathway.
Addressed to: Sheffield Teaching Hospital NHS Foundation Trust
AI-generated concerns summaryConcerns were raised about the self-harm risk posed by corded telephones suspended at head height in anti-ligature cells and the potential for limited telephone access in the CSU to hinder prisoners in crisis from contacting support services.
Addressed to: HMP Lincoln; Ministry of Justice
AI-generated concerns summaryThe coroner noted a national shortage of maxillofacial surgeons, which could impact patient care. This shortage was linked to the long training period, a significant part of which is not NHS-funded and perceived as unattractive to prospective surgeons.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted propranolol's high toxicity even at small doses and the lack of a specific antidote, requiring only supportive hospital treatment. There is a need for doctors, especially GPs, to be aware of these serious consequences.
Addressed to: Medicines and Healthcare products Regulatory Agency