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 insufficient supervision for a junior doctor, a lack of full understanding of the sepsis protocol by clinicians leading to ineffective initiation, and a delay in senior review and ITU team involvement.
Addressed to: Milton Keynes University Hospital Litigation
AI-generated concerns summaryThe coroner identified a lack of understanding among road users regarding the reporting of obstructions, requesting that consideration be given to making the public aware of the dangers and encouraging them to report hazards to authorities.
Addressed to: BCP Council; Department for Transport; Dorset Council; Dorset Police; National Highways
AI-generated concerns summaryConcerns included a lack of integrated systems for online pharmacies, enabling excessive medication and limiting GP information sharing, alongside inaccurate mental health care plans, insufficient staff training, and inadequate observation documentation on the ward.
Addressed to: Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient staffing and a ward layout that hindered effective observation of high-risk patients on Bargeod ward. Additionally, falls prevention measures were ineffective, and a plan for managing enhanced care in a single-room environment had not been communicated.
Addressed to: N/A
AI-generated concerns summaryThe coroner raised concerns regarding long ambulance waiting times and patient deterioration, noting this was due to ambulance shortages from high demand and emergency department offload delays. Similar delays in emergency departments meant frail patients received treatment in challenging circumstances.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about low awareness among UK nationals in Bali regarding methanol poisoning from counterfeit alcohol. They noted a lack of UK Government publicity on this risk, suggesting this information could help prevent future deaths.
Addressed to: Foreign Secretary
AI-generated concerns summaryThe coroner identified significant A&E waiting times and a lack of hospital beds impacting patient care, noting that capacity issues prevented direct ward entry for patients like Mr Stanley and were replicated regionally.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that Oncology Consultants continue to lead care for APML patients at Alder Hey, despite expert opinion that Haematologists should lead coagulopathy management due to significant bleeding risks. A national shortage of Haematologists limits the Trust's ability to address this.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryInadequate recording of information, especially telephone conversations, and a lack of comprehensive planning for home leave and discharge were noted. The coroner also identified insufficient overall situational awareness regarding the individual, including reconciling conflicting accounts.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of national guidance for identifying and caring for vulnerable prisoners, alongside concerns about the implementation and resourcing of the keyworker programme. Irregular record-keeping by prison staff on Prison NOMIS was also highlighted.
Addressed to: HM Prison and Probation Service, NHS England and HMP Guys Marsh
AI-generated concerns summaryThe GP practice's EMIS system lacks a scheduled task feature or prominent alerts for future follow-up, placing responsibility on patients to initiate contact and risking missed necessary investigations.
Addressed to: Egton Medical Information Systems
AI-generated concerns summaryThe coroner highlighted significant understaffing in the Radiology department, exacerbated by a national shortage of trainee posts and the expectation for all scans to be reported within an hour. A proposed solution of call handlers was delayed due to cost.
Addressed to: Gloucestershire Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inadequate risk assessments that led to reduced observations. There were also concerns about miscommunication between the NHS Trust and emergency services regarding patient risk levels, including the absence of a single point of contact for updates.
Addressed to: Essex Partnership NHS Foundation Trust; Essex Police
AI-generated concerns summaryThe coroner identified a lack of specific training for prison officers on managing CPR for individuals on top bunks. Concerns were also raised regarding the level of CPR and airway management training for nurses working in detention settings.
Addressed to: HM Prison and Probation Service, NHS England
AI-generated concerns summaryThe emergency response procedure delays the provision of life-saving equipment by requiring assessment before collection. Patient observations were predictable, prescriptive, and lacked effective risk assessment.
Addressed to: Inmind Healthcare Group
AI-generated concerns summaryThe coroner noted an unclear process within the primary care complaints team for ensuring clinical reviews are fully informed by GP practice rationale and for sharing review details back to practices and networks for learning.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of clarity on offering non-invasive ventilation to patients with respiratory conditions and noted insufficient recognition of patient deterioration. This was attributed to inconsistent fluid chart use and a lack of care continuity for patients on the Acute Medical Unit.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the safety of ambulance discharge for patients with significant co-morbidities and morbid obesity, following a fatal fall sustained when exiting the ambulance.
Addressed to: North East Ambulance Service NHS Foundation Trust
AI-generated concerns summaryParents of an infant at higher risk of Sudden Infant Death Syndrome (SIDS) did not receive discharge advice and documentation from UCLH, and the hospital could not provide clear evidence that this omission had been remedied.
Addressed to: Department of Health & Social Care; University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the lack of suitable care options and appropriate therapies for individuals with neurodiverse conditions experiencing acute mental health crises. Issues included the unsuitability of standard inpatient units and home treatment teams, and a shortage of specialized psychological interventions.
Addressed to: NHS England; NHS England