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 coroner identified concerns regarding data recording and retention practices at HMP Thameside, including lost documents and incomplete records, and the absence of a written policy for suspected drug swallow incidents.
Addressed to: HM Inspectorate of Prisons; HM Prison and Probation Service; HMP Thameside; Ministry of Justice
AI-generated concerns summaryExtensive delays in the serious incident investigation report exceeded NHS guidance, hindering timely implementation of actions to address identified issues like clinical record keeping and risk assessments, and compromising evidence quality due to late memory capture.
Addressed to: Care Quality Commission; Tees, Esk and Wear Valley NHS Foundation Trust
AI-generated concerns summaryDiscrepancies existed in laxative administration records, and staff faced challenges assessing the patient's condition due to learning disabilities. Concerns were raised about medical staff's appreciation of the risk of respiratory compromise from abdominal distension related to laxative use.
Addressed to: Swansea Bay University Health Board
AI-generated concerns summaryConcerns were raised regarding barriers for mental health staff to access physical health specialists without emergency department use, incompatible electronic record systems hindering information transfer between trusts, and insufficient guidance for nursing staff on Venous Thromboembolism risk assessments.
Addressed to: Department of Health and Social Care; Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that 'observable bay nursing' for high-risk patients was not consistently maintained due to staff having to perform other urgent tasks and a lack of understanding of the risk involved. This system requires adequate staffing and a cultural shift among staff to effectively prevent avoidable falls.
Addressed to: Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner identified that delayed hospital discharges for frail elderly patients, caused by a lack of social care availability, increase the risk of deconditioning and infection.
Addressed to: Department of Health and Social Care; Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner raised concerns about delays in a patient receiving clinical assessment and treatment following a fall. These delays were attributed to ambulance attendance delays and a backlog of ambulances waiting to unload at the hospital due to sustained pressure on services.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted significant delays in Emergency Department clinician assessment and diagnostic scanning, stemming from high patient demand and staff shortages. These delays contributed to patient deterioration before treatment could commence.
Addressed to: NHS England
AI-generated concerns summaryExpectant mothers were not provided with clear, accessible information regarding sensitising events for Rhesus status and when to contact maternity triage for advice, potentially delaying early intervention.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner identified ongoing concerns regarding the system for communicating concerning radiological findings, even though a new protocol for unsuspected cancers and critical findings has been approved for adoption.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryDelays in patient referrals between trusts were noted due to incompatible information sharing systems and reliance on postal services. There were also delays in patients accessing cardiology clinics and specialist echocardiograms due to resource availability.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe Housing Association lacked a system to ensure escalation of non-contact cases from their subcontractor Liberty, and no audit system to monitor referral outcomes or identify frequent non-escalation issues.
Addressed to: L&Q Group Housing
AI-generated concerns summaryThe coroner noted significant ambulance wait times for frail elderly patients with hip fractures due to demand and resource limitations, further exacerbated by offload delays at Emergency Departments.
Addressed to: Department of Health and Social Care; Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner noted concerns regarding long ambulance and Emergency Department delays, attributed to service demand and patient flow issues, which led to a delay in pressure ulcer prevention measures. Such delays were reported as an ongoing and widespread issue.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted staff used multiple, inconsistent systems for recording chemotherapy administration, an instance of incorrect patient data entry, and a lack of recent audits on record-keeping on the Laurel Unit.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted prolonged waits for ambulance arrival, delays in transferring the patient to the Emergency Department, and further delays in securing a ward bed, all of which posed significant risks to elderly and frail patients with hip fractures.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified inadequate discharge procedures, including a lack of discharge notes, medications, and follow-up, and poor record-keeping regarding post-discharge infection concerns. There was also insufficient inter-hospital communication about the patient's complex treatment and care.
Addressed to: Leeds Teaching hospitals and York Hospital Legal trust
AI-generated concerns summaryConcerns were raised regarding junior doctors' incorrect prescribing despite clear guidelines and inadequate VTE assessments. The coroner also noted consultants not accepting responsibility for monitoring junior doctors' prescribing, and a lack of continuity of care for patients.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner identified missed antibiotic doses without escalation and insufficient consultant input during a holiday period. Concerns also included issues with the ICU referral process, critical care outreach availability, and the absence of a specialist liver team discussion.
Addressed to: NHS England; Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted Bridgewood House lacked a clear plan for extricating an unwell or uncooperative person from the first floor during a medical emergency. This was compounded by the building's narrow layout, residents' potential uncooperation, and the known agitation side-effect of Naloxone.
Addressed to: HM Prison and Probation Service