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 summaryThe coroner noted the continued use of unmodified lorry-mounted cranes poses a crush injury risk to operators, urging dissemination of information about safety modifications and operational risks throughout the industry.
Addressed to: Department for Transport; Health and Safety Executive; Titan Containers Limited
AI-generated concerns summaryTraining for midwives on correct cord blood sampling techniques was insufficient, potentially leading to inaccurate pH results and false reassurance. There were also gaps in training for neonatal resuscitation, specifically regarding UVC/IO access and the timely provision of blood transfusions.
Addressed to: North West Anglia NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the limited experience of midwives attending a home birth, noting there are no specific regulatory requirements for training or ongoing exposure to the unique issues that can arise in such births.
Addressed to: Nursing and Midwifery Council
AI-generated concerns summaryThe falls risk assessment document at Birmingham Heartlands Hospital lacked prompts for staff to consider or document patient attachments and their relevance to falls risk. Additionally, documentation of attachments on other forms did not trigger a reconsideration of the falls risk assessment.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of process to ensure significant, unexpected changes in follow-up X-rays, especially those highly suggestive of tuberculosis, are highlighted to referring clinicians in a timely manner for discharged patients.
Addressed to: Medica Reporting Service
AI-generated concerns summaryThe coroner raises concerns about the lack of integrated electronic records between alcohol and drug addiction services and primary community mental health teams. This hinders effective sharing of patient safety information, particularly for dual diagnosis cases, increasing the risk of important details being lost.
Addressed to: Swansea Bay University Health Board
AI-generated concerns summaryThe coroner noted limited documentation of wound management and pressure care, with uncertainty regarding adherence to care plans. Additionally, the same individual served as Manager and Registered Nurse for two consecutive days.
Addressed to: Maria Mallaband Care Group and Countrywide Care Homes
AI-generated concerns summaryThe coroner noted the significant number of prisoners with mental health issues and highlighted the need for mental health experts to attend all ACCT review meetings, as their absence meant issues went unidentified.
Addressed to: Ministry of Justice (Coroners)
AI-generated concerns summaryThe coroner noted a significant number of open cases of rape or serious sexual assault, coupled with over 20 vacancies for Detective Constables, leading to delays in securing best evidence and impacting the quality of work.
Addressed to: Devon and Cornwall Police; Network Rail; Police and Crime Commissioner
AI-generated concerns summaryThe Trust's guideline summary for thrombosis prevention was inaccurate, leading to a high-risk patient receiving low-risk prophylaxis. This raises concerns about the potential for other patients to have received inappropriate treatment.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner noted issues with the accurate completion of the Falls Risk Assessment and the lack of reassessment of falls risk following family reports of the deceased's compromised mobility. The Trust's investigation did not identify these concerns.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryInadequate risk assessment and planning for a patient's leave, and missed opportunities to address escalating risk factors, were identified. Concerns also noted suboptimal care coordination and uncompleted actions from the review.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of a direct medical review before a patient with cardiac risk factors was discharged from the Ambulatory Care Unit. There was also no policy governing discharges from this unit without a medical review.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryThe Trust's investigation into Mr Howe's death did not fully consider his mental health service contacts, lacked critical analysis, and omitted the patient's perspective on access, thus limiting learning opportunities.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted GMP staff's insufficient understanding of high-risk assessment for missing voluntary mental health patients and applying "golden hour" guidance. Concerns included poor documentation, information sharing, and the unclear effectiveness of new training and systems.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner raised concerns regarding specialist training for staff in the moving and handling of individuals, especially after a fall.
Addressed to: Bluebird Care (Kent)
AI-generated concerns summaryThe coroner noted unclear guidance for clinicians regarding DVT risk reduction in young, immobile patients on oral contraception post-accident, which can lead to differing approaches and insufficient recognition of fatal risks.
Addressed to: National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThere is limited national guidance and evidence on the optimal treatment for oesophageal strictures, specifically regarding the number of dilatations and the timing for considering stenting, given the associated risks of perforation.
Addressed to: National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThe coroner identified insufficient exploration of reported violence and substance misuse, and a lack of appropriate referrals. Concerns were also raised about uncoordinated inpatient and premature community team discharges, alongside inadequate patient engagement and no consultant psychiatrist follow-up.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryLong waiting times for neurology outpatient appointments were noted due to capacity issues, including a three-year vacancy for a substantive neurology consultant. This resulted in a missed opportunity for earlier specialist assessment.
Addressed to: NHS England; NHS Improvement