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 report highlights a national shortage of appropriate care placements and insufficient hospital resources, which meant a patient requiring constant supervision for cognitive impairment could not receive adequate care in an Emergency Department, contributing to a fall.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner notes a lack of national distribution of bath safety advice to healthcare professionals and parents/carers. There are concerns that bath seats may give a false sense of security, as parents may be unaware they are not safety devices.
Addressed to: Office of Product Safety and Standards
AI-generated concerns summaryThe coroner raised concerns regarding the lack of timely treatment for Mrs. Hutchins' cardiac condition despite an abnormal ECG and elevated Troponin, noting she did not receive a medical review for four days following the abnormal results.
Addressed to: Royal United Hospital
AI-generated concerns summaryThe coroner noted a lack of clinician appreciation for the need for additional steroid therapy in patients with Addison's disease following trauma. There were insufficient guidelines and documentation prompts in both hospital and pre-hospital settings to address this risk effectively.
Addressed to: Association of Ambulance Chief Executives; National Institute for Health and Care Excellence; NHS England; West Midlands Ambulance Service University NHS Foundation Trust; Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryNo single effective system consolidated and shared information about individuals at risk across multiple NHS Trusts, police forces, and local authorities. This was compounded by the absence of a national 'risk flagging' system.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identifies a lack of restrictions on who can operate mobility scooters, with no requirements for vision, cognitive ability, or substance influence. The report also notes the absence of legal registration or ownership records, unlike other vehicles.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner raised concerns about the application of legislative exemptions for speed limits and blue lights to volunteer blood bike services. The report questions whether these exemptions apply when routine samples are transported under a courier contract.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted that the collision occurred on an all-lane running smart motorway where there was no safe place for the driver to park, such as a hard shoulder.
Addressed to: National Highways
AI-generated concerns summaryThe coroner raised concerns regarding the lack of increased orthogeriatric provision for elderly patients with hip and pelvic fractures and co-morbidities, noting that improved access to this specialist care could prevent future deaths.
Addressed to: Department of Health and Social Care; Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inconsistent adoption of a Triage System in Accident and Emergency, which impedes meaningful escalation of care and appropriate senior oversight. Concerns were also raised about untimely communication with next of kin and delays in signing off S.I. reports.
Addressed to: Hereford County Hospital
AI-generated concerns summaryThe coroner identified an absence of a protocol for prompt and secure radiology report delivery. This meant a patient's CT scan report was delayed and unconfirmed after transfer, leading to doctors not following up on potential bowel injury signs.
Addressed to: Royal Stoke University Hospital and Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified a need for a robust national system to capture and record fatal and near-fatal anaphylaxis cases, and to fund appropriate research to improve understanding and prevent future deaths.
Addressed to: Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; NHS England; UK Fatal Anaphylaxis Registry
AI-generated concerns summaryThe coroner identified delays in the Autism Strategy work, insufficient progress in complex case management, and expressed a lack of reassurance regarding actions from the Serious Incident Investigation process.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust and Nottinghamshire Integrated Care Board
AI-generated concerns summaryThe coroner noted that finite resources contribute to long wait times for assessment of young people, which places them at risk. It was suggested that earlier diagnosis and professional intervention, alongside support for parents, might have prevented the death.
Addressed to: Children’s Commissioner for England; Department for Education; Department of Health and Social Care
AI-generated concerns summaryMrs. Gormley's falls risk assessment and care plan documents were not updated after multiple falls, meaning staff might have been unaware of her increased risk and mitigation measures were not considered. The report noted concerns that staff at Latimer Court may not understand their duties to update resident documentation.
Addressed to: Barchester Healthcare; Weightmans LLP
AI-generated concerns summaryThe coroner noted a significant nursing staff shortfall in the community mental health team, which meant there was no capacity to reallocate a care coordinator when the patient's relationship with their existing coordinator broke down.
Addressed to: Kent & Medway NHS & Social Care Partnership Trust; NHS Kent and Medway Integrated Care Board
AI-generated concerns summaryThe coroner identified a risk of future reoccurrence due to a deficit in operational hours for SECAMBS, resulting in delayed response times and compromised patient safety. This was attributed to a lack of available staff and handover delays at hospitals.
Addressed to: Department of Health and Social Care; South East Coast Ambulance Service
AI-generated concerns summaryMrs Robinson did not receive a medical review or comprehensive risk assessment prior to her Home Treatment Team discharge. Additionally, there was no multi-disciplinary team discussion or communication with her family and care agency regarding the withdrawal of support.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding road safety in Hull's Lowgate area on busy Friday and Saturday nights, where high numbers of intoxicated pedestrians interact with active traffic, including dangerous taxi manoeuvres, and insufficient crossing facilities.
Addressed to: Department for Transport; Hackney Carriage Association for the area of Kingston Upon Hull; Kingston Upon Hull Council
AI-generated concerns summaryThe coroner noted limited medical awareness of Immersion Pulmonary Oedema and the absence of specific standards for full face snorkel masks during their development. There were also concerns about insufficient communication of safety warnings to existing mask owners regarding use by individuals with cardio-respiratory conditions.
Addressed to: Decathlon UK; General Medical Council; National Trading Standards; Royal Society for the Prevention of Accidents