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 noted inadequate personal care was provided to RA in hospital, evidenced by photographic findings upon his return to the nursing home. The subsequent NHS Trust investigation was significantly flawed, failing to incorporate critical evidence.
Addressed to: Mid and South Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted significant delays in allocating a bed upon hospital entry, insufficient nursing and clinical staff, and gaps in nursing documentation and communication of patient status within the Emergency Department.
Addressed to: Betsi Cadwaladr University Health Board; Welsh Ambulance Service Trust
AI-generated concerns summaryAdferiad lacked a system for retaining service user correspondence, which led to individuals being closed to the service. Communication was restricted to writing only, and waiting times for support were long due to resource limitations.
Addressed to: Adferiad Recovery; Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted a lack of shared understanding among clinicians at the trust regarding the protocol for high-risk home deliveries. Additionally, the report described a need to enhance communication channels for midwives to discuss differing views with senior management.
Addressed to: Homerton Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the Agency did not apply a clear threshold for vessel stability assessments following significant modifications, relying instead on skipper reassurances and informal visual checks. This raises concerns that other modified vessels may be operating without proper safety evaluations.
Addressed to: Maritime & Coastguard Agency
AI-generated concerns summaryThe coroner indicated that action should be taken to prevent future deaths.
Addressed to: Birmingham and Solihull Integrated Care Board; Birmingham and Solihull Mental Health NHS Trust; Birmingham City Council; Department of Health and Social Care; NHS Digital; NHS England
AI-generated concerns summaryThe care plan for Mr Burns inaccurately recorded his dietary needs, failing to specify a blended diet. Documentation transferred to ambulance services upon his hospital admission was also not checked, meaning his care needs were not reliably communicated.
Addressed to: Highgrove Rest Home
AI-generated concerns summaryThe coroner noted that the refusal of anti-coagulation medication was not brought to the attention of medical staff. There is no electronic prompt or alert to notify the medical team when prescribed anti-coagulation medication is not administered.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate systems for monitoring and communicating high clozapine levels, and a lack of staff understanding in interpreting and responding to them. This included ineffective medication change processes and insufficient learning from previous concerns.
Addressed to: Birmingham and Solihull Mental Health Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted delays in urgent gastroscopies for A&E patients with gastric bleeds pending hospital bed allocation. Additionally, an allocated consultant did not review a patient on their ward list as the patient remained physically in A&E.
Addressed to: Royal Stoke University Hospital
AI-generated concerns summaryThe coroner identifies an ongoing impasse between organisations regarding a permanent safe system for communicating conveyor movement and the training of operatives on travellator controls. This involves the lack of agreed standards for competency assessment and insufficient training provision.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner notes inadequate player protection tools for problem gamblers, which lack meaningful interaction or intervention. Additionally, Betfair's algorithm failed to flag a problem gambler despite escalating activity, due to averaging practices among customers and the operator's reliance on regulatory standards over best practice.
Addressed to: Betfair; Flutter UK & Ireland; Department for Culture, Media and Sport; Gambling Commission
AI-generated concerns summaryThe coroner noted the ease with which children illegally access hire e-scooters. This is attributed to inadequate age and identity verification during account transfer and providers' inability to detect child bank accounts, alongside limited regulatory oversight.
Addressed to: Collaborative Mobility UK; Department for Transport; West Midlands Combined Authority
AI-generated concerns summaryThe coroner noted continued lengthy ambulance and patient offload delays in North Wales' Emergency Departments. Concerns were also raised about the lack of evidence of Local Authorities' involvement in addressing patient flow issues due to social care deficiencies.
Addressed to: Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust and North Wales Local Authorities
AI-generated concerns summaryThe coroner noted a lack of training for pharmacy delivery agents on managing fallen elderly patients at home, and a lack of clarity regarding their roles and responsibilities in such situations.
Addressed to: General Pharmaceutical Council; Orchard 2000 Pharmacy
AI-generated concerns summaryThe coroner identified challenges for officers in determining when to commence CPR, noting that if in doubt, first aiders should move straight to CPR. There was also a need for more proactive team support and a 'helicopter view' from a secondary safety officer during resuscitation.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner raises concerns regarding the provision of regular and periodic training for all drivers at 3D Trans Ltd in coupling and uncoupling procedures, following a series of rollaway incidents.
Addressed to: 3D Trans, Health and Safety Executive
AI-generated concerns summaryA significant respiratory abnormal acidosis reading from a venous blood gas sample was not followed by further investigation, which the coroner identified as a potential training or communication issue.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner identified concerns about CATT's generic history recording leading to under-appreciated risk, and their focus on admission alternatives potentially causing inappropriate discharges. Gaps were noted in requiring on-call psychiatrist discussion for CATT discharges and resolving differing psychiatric team assessments.
Addressed to: West London NHS Trust
AI-generated concerns summaryThe coroner noted limited evidence of improved communication and working relationships between stroke and neurosurgical teams, and the stroke team's limited understanding of NICE guidance for Decompression Craniectomy referrals. Joint case discussion and learning opportunities were also limited.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust