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 raises concerns that despite recent safety improvements, cyclists remain at risk at the road traffic collision location, indicating a need for further measures.
Addressed to: South Tyneside Council
AI-generated concerns summaryThe coroner highlighted concerns over the lack of effective recording for intravenous fluids in the emergency department, deficiencies in patient information management and documentation by medical staff, and the poor standard of the incident investigation report.
Addressed to: Milton Keynes University Hospital, Care Quality Commission, Bedfordshire, Luton, and Milton Keynes Integrated Care Board and The General Medical Council
AI-generated concerns summaryConcerns identified gaps in safeguarding referral processes, including review timescales, staff training on thresholds, and inter-agency communication. The report also notes questions about the adequacy of mental health support post-discharge and service resourcing.
Addressed to: Reading Borough Council, Berkshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the hospital's internal postal system for urgent notifications between teams, as there was no process to ensure urgent matters were brought to attention immediately or that mail was dealt with in a timely manner.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted concerns regarding delays in completing the implementation of proposed changes, including a new consultant model, standardised documentation, and involving families in decision-making.
Addressed to: CPFT
AI-generated concerns summaryThe coroner noted continuing delays in ambulance response and hospital handovers, linked to patient flow issues caused by social care deficiencies. Concerns were raised about the lack of meaningful evidence regarding Local Authorities' involvement and progress in addressing these inter-agency problems.
Addressed to: Betsi Cadwaladr University Health Board; North Wales Local Authorities; Welsh Ambulance Service Trust
AI-generated concerns summaryThe coroner noted significant and continuing delays in ambulance arrival times for patients and in the handover of patients from ambulances to hospital staff. Concerns were raised that these persistent delays could contribute to future deaths.
Addressed to: Betsi Cadwaladr University Health Board; North Wales Local Authorities; Welsh Ambulance Service Trust
AI-generated concerns summaryThe coroner identifies risks of inadvertent overdose due to the visual similarity of different strength carbimazole tablets and their resemblance to aspirin. The community dispensing process for carbimazole does not adequately mitigate this risk.
Addressed to: Medicines & Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted delays between GP referrals and assessments by the Crisis Review Team, with uncertainty about whether this was due to GP understanding, CRT prioritisation, or triage effectiveness.
Addressed to: Stockport Integrated Care Partnership
AI-generated concerns summaryThe coroner identified inadequate handling of a crisis line call by a clinician, including a lack of empathy and failure to record the interaction. Additionally, East London NHS Foundation Trust provided crucial evidence, such as call recordings and investigation reports, with significant delays to the coroner's office.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in staff communication concerning unescorted leave decisions and critical patient risk information. Inadequate risk assessment processes for leave and delays in reporting a missing patient with insufficient communication of their serious risk were also noted.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified significantly extended Category 2 ambulance response times, which contributed to the patient's deterioration and death before hospital arrival. These widespread delays were attributed to high ambulance demand and prolonged handover times at A&E departments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe Practice did not implement learnings identified in its Significant Event Analysis, despite noting shortcomings in their practice. As of the inquest date, no plans or timescales for implementation were available.
Addressed to: Clacton Community Practices
AI-generated concerns summaryThe coroner identified a risk that the Nearest Relative Power could lead to patient discharge despite them meeting detention criteria, due to a lack of thorough procedure or legal test for clinicians to apply.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns that qFIT test results, requested for Ms Coogan in July and September 2022, were not received. The report identifies this as a matter for investigation to determine if there is a system issue.
Addressed to: Ritchie Street Group Practice
AI-generated concerns summaryThe coroner noted insufficient staff preparedness and policy guidance for safely managing patients who abscond, alongside uncertainty regarding police assistance in such situations.
Addressed to: East London NHS Foundation Trust; Home Office; Metropolitan Police Service; NHS England
AI-generated concerns summaryInadequate history taking led to assumptions about oxygen saturation based on BMI, monitoring escalation was lacking despite a high NEWS score contrary to policy, and the PE policy had inconsistent application and unclear wording.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in discharge planning, including no planned follow-up, lack of family involvement, and delayed GP notifications. There were also concerns about the inadequate weight given to the individual's alcohol problems during risk assessment.
Addressed to: Northumberland, Tyne and Wear NHS Trust
AI-generated concerns summaryThe coroner identified potential for a lack of understanding among clinicians regarding urgent mental health referrals, and inconsistent access to mental health records hindering information sharing. Concerns were also raised that drug/alcohol references or perceived intoxication could lead to missed mental health diagnoses or delayed identification of psychosis.
Addressed to: Bloomfield Medical Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust and North West Ambulance Service
AI-generated concerns summaryA recurring puddle on a path, caused by a drain discharge, creates a slip hazard in wet weather, and the coroner noted that remedial work is needed to prevent further accidents.
Addressed to: Carlisle CORONER; Cumberland Council