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 identified delays in prescribing and administering therapeutic medication for psychosis, including a failure to provide urgently prescribed medication. Concerns were also raised about the Trust's internal investigation, which did not involve the senior pharmacist or the family.
Addressed to: Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an inconsistency between the Patient Information Leaflet and the British National Formulary regarding suicidal behaviour as a potential side effect of sertraline. This could mean prescribers are unaware of this risk or do not discuss it with patients.
Addressed to: National Institute for Health and Care and Excellence; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner raises concerns about considering exceptions to patient confidentiality in mental ill-health cases, where informing third parties could provide crucial non-medical support.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a risk of future deaths if existing traffic measures around the school are not reviewed and investigated for their adequacy.
Addressed to: Stoke on Trent City Council
AI-generated concerns summaryThere is no clear pathway for details of private psychiatrist consultations and prescribed medications to be shared with NHS Trusts, which could result in relevant history being lost during a crisis.
Addressed to: Royal College of Psychiatrists, Sussex Partnership Foundation Trust
AI-generated concerns summaryThe coroner identified failures in assessing risk of harm, a decision to reduce observations contrary to policy, and an inadequate emergency response. Concerns were also raised about the credibility of observation records and misleading incident reports.
Addressed to: Department of Health and Social Care; North East London Foundation Trust
AI-generated concerns summaryThe coroner notes a lack of signage to alert westbound drivers of a sharp left-hand bend on Old Oundle Road, which, combined with water beyond the bend, creates a risk of future incidents and death.
Addressed to: Cambridgeshire County Council
AI-generated concerns summaryThe coroner raised concerns regarding the absence of signage to alert westbound drivers on Old Oundle Road about a sharp left-hand bend, a hazard compounded by a pond located beyond the bend.
Addressed to: Peterborough City Council
AI-generated concerns summaryDelays of approximately 12 hours for mental health patients to be admitted after a Section 2 assessment if no bed is available, meaning they cannot be legally detained and remain in A&E without specialist mental health care.
Addressed to: NHS England; NHS Improvement
AI-generated concerns summaryHospital doctors did not take a comprehensive psychiatric history, leading to missed opportunities for risk assessment of patients with suicidality. The lack of formal psychiatric liaison cover at QMH also increases risks for vulnerable patients.
Addressed to: St Georges University Hospital NHS Foundation Trust, The Roehampton Surgery and NHS South West London Integrated Care Board
AI-generated concerns summaryThe coroner noted gaps in Adult Social Care's monitoring and follow-up over several years despite known self-neglect. Concerns were also raised about a safeguarding assessment that was prematurely closed based on limited information and without awaiting key reports.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryThe Health Board's internal investigations are significantly delayed, with actions often unrealistic or not completed by their due dates, hindering timely identification of learning needs and training implementation.
Addressed to: Betsi Cadwaladr University Local Health Board
AI-generated concerns summaryThe coroner noted concerns regarding insufficient staffing levels at the care home, where two carers for 17 residents meant individuals were left unmonitored, potentially contributing to a resident's fall.
Addressed to: Silver Birches Care Home
AI-generated concerns summaryThe coroner noted concerns regarding an inadvertent reduction in a patient's steroid dosage at Royal Cornwall Hospital and the lack of disclosure of this error. Additionally, the British National Formulary's Prednisolone guidance lacks information on the risk of bowel perforation in patients with diverticular disease.
Addressed to: National Institute for Health and Care Excellence; Royal Cornwall Hospital Trust
AI-generated concerns summaryThe coroner identified issues with the school nurse's medication review, which was conducted without the physical medication and used an incorrect allergy action plan. There was also a lack of follow-up to ensure in-date medication and complete documentation were provided.
Addressed to: Department of Health and Social Care, London Ambulance Service NHS Trust 2, Royal London Hospital, Bromley by Bow Health Centre, British Society for Allergy and Clinical Immunology, Bow School and Compass Wellbeing Tower Hamlets Steel’s Lane Health Centre
AI-generated concerns summaryThe provided document extract contains boilerplate text regarding report distribution and recipients, but does not detail specific coroner's concerns for future death prevention.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a deficiency in the regulatory framework for HMOs accommodating vulnerable persons, which means there is no requirement to assess and manage scalding risks or for regulatory oversight by bodies like CQC or HSE.
Addressed to: Care Quality Commission; Department of Health and Social Care; Supported Independence Limited
AI-generated concerns summaryThe coroner identified gaps in comprehensive airway strategies for anticipated difficult airways, including a lack of structured planning, universal use of NAP4 algorithms, and robust daily equipment checks. Additionally, the Mortality Review policy was not followed, delaying serious incident review and Trust learning.
Addressed to: Derby and Burton NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a clinician's approach of relying on memory for patient information instead of maintaining proper records, identifying this as a risk for future patients.
Addressed to: Spire Hospital
AI-generated concerns summaryThe coroner noted issues with the transfer of critical patient information between an NHS hospital and a private hospital, alongside a lack of clarity among private hospital staff regarding responsibility for removing banned items upon admission.
Addressed to: NHS England; Priority Group