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 summaryMulti-Disciplinary Team meetings were flawed due to an incorrect understanding of the patient's medication status, resulting in a delay in prescribing antidepressants and sleeping tablets. The subsequent Serious Incident Investigation by the NHS Trust was found to be inadequate.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryLabels on high protein supplements and drinks do not adequately warn consumers about potential dangers for individuals with undiagnosed urea cycle disorders. The coroner suggests labels should prominently display warnings about risks, symptoms, and the importance of seeking immediate medical advice.
Addressed to: NHS England; NHS Improvement; Food Standards Agency
AI-generated concerns summaryThe coroner raises concerns about the absence of national guidance and training protocols for the insertion and correct placement verification of nasogastric decompression tubes, noting that misplacement can be fatal.
Addressed to: Health Education England; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner identified that the pallet truck and unloading method were incompatible and unsafe, posing a risk of falls from truck tailgates. Concerns were also raised that health and safety procedures, equipment suitability, and user permission had not been reviewed or changed.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner raises concerns about the inconsistency between NHS guidance for notifying patients of Mycobacterium Chimaera infection risk (from January 2013) and evidence of infections occurring significantly earlier, which may lead to delayed diagnosis and harm for affected patients.
Addressed to: UK Health Security Agency
AI-generated concerns summaryThe coroner noted the absence of a spare breathing apparatus cylinder for stand-by divers and the inappropriate acceleration of safety-critical dive training. Concerns also included the lack of a dedicated defibrillator for dive support staff and an inconsistency in minimum safety pressure levels for breathing apparatus.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner noted insufficient monitoring of the deceased's deteriorating condition after a PEG tube insertion, and abdominal pain complaints were not escalated to a senior doctor to consider a possible bleed. A review of post-PEG insertion procedures and protocols is recommended.
Addressed to: Milton Keynes University Hospital
AI-generated concerns summaryBradford Council lacked a single point of overview or a system for coordinating its various departments' involvement with the deceased child, both before and after her death. This absence made it difficult for the Council to identify and learn lessons from the case.
Addressed to: City of Bradford Metropolitan District Council
AI-generated concerns summaryThe coroner noted that recommendations from a previous report remained outstanding and were not known at the inquest. Concerns were raised about insufficient measures to protect vulnerable persons using escalators, especially when lifts are unavailable.
Addressed to: Range
AI-generated concerns summaryInsufficient national guidance and training on angioedema types meant clinicians lacked awareness of ACE Inhibitor angioedema complexity and treatment pathways. The BNF also lacked information on racial disparities and alternative medications.
Addressed to: NHS England; NHS National Patient Safety Alerting Committee
AI-generated concerns summaryThe coroner identifies concerns regarding a communication breakdown between the GP and patient on the steps required for a mental health referral, noting an absence of an automatic referral system after sobriety and no written confirmation of responsibilities.
Addressed to: Beaufort Road Surgery
AI-generated concerns summaryThe coroner noted the local authority lacked statutory power to install sprinkler systems in private dwellings without occupant consent. This meant Mr. Keating's flat was the only one not connected to the tower block's fire safety system.
Addressed to: Home Office; Leeds City Council
AI-generated concerns summaryThe coroner noted delays in implementing policies and an electronic monitoring system, as well as concerns about record integrity and alarm audibility. There were also issues with malfunctioning sensors and unaddressed safeguarding and falls risks.
Addressed to: Broadlane View Care Home
AI-generated concerns summaryThe coroner noted inconsistent use of Keilland’s forceps and raised concerns about the lack of clear guidance on either maintaining skill levels and managing complications if used, or on alternative obstetric methods if they are abandoned.
Addressed to: NHS England; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted significant deficiencies in pressure sore prevention and management, including an incorrect initial risk assessment, delays in implementing preventative measures, and poor adherence to care protocols such as the SSKIN bundle and regular repositioning.
Addressed to: Royal United Hospitals
AI-generated concerns summaryThe coroner identified delays in emergency response for an unresponsive patient, specifically concerning the time taken to obtain monitoring equipment, for a doctor to attend, and to call an ambulance. Existing staff training and emergency response systems may not ensure an immediate and effective response in such situations.
Addressed to: Nottingham Healthcare Trust
AI-generated concerns summaryInconsistent care records indicated a service user was not at risk of choking when they clearly were, and a senior manager demonstrated an under-appreciation of this risk. This approach could prevent necessary preventative measures from being implemented for vulnerable service users.
Addressed to: Northern Care Limited
AI-generated concerns summaryHAL did not specifically consider background visual interference as a potential accident factor, despite it being raised years prior. Additionally, the visibility of white-coloured vans at uncontrolled crossings was noted, with a suggestion for side profile lights.
Addressed to: Heathrow Airport
AI-generated concerns summaryThe coroner identified insufficient formal policy for Care Coordinator handovers, leading to the patient lacking an allocated coordinator for weeks. Concerns also included unclear post-discharge oversight and safety-netting responsibilities, and that the patient's risk and care plans were not updated.
Addressed to: Essex Partnership NHS Trust
AI-generated concerns summaryThe patient did not receive a scheduled hysterectomy, as she 'slipped out of the care pathway' without clear explanation for this occurring. The VTE risk assessment also omitted relevant factors, limiting its effectiveness.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care; NHS England