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 JRCALC guidance for footling breech presentations is insufficiently robust, leading to delays in transferring mothers to hospital. There is also a lack of consultant midwives providing obstetric support, guidance, and training within ambulance services.
Addressed to: Joint Royal Colleges Ambulance Liaison Committee and CEO Association of Ambulance Chief Executives
AI-generated concerns summaryThe coroner identified that CWB staff did not ensure Sarah's safety after she was distressed, and their systems were insufficiently robust to manage and safeguard students with mental health problems. There was also a lack of national guidance implementation and external oversight of the service.
Addressed to: Surrey University, NHS England, Universities Minister and University of Surrey
AI-generated concerns summaryTLC nursing and care lacked a formal review system to trigger multi-disciplinary meetings when a resident's condition deteriorated, and had no mechanisms to monitor if care plans were being met.
Addressed to: TLC Nursing and Care
AI-generated concerns summaryConcerns included significant inaccuracies in the resident's care plan, non-adherence to monitoring requirements for weight, blood sugar, and fluid intake, inappropriate medication administration, and insufficient auditing of care plans.
Addressed to: Windmill House Care Home
AI-generated concerns summaryInsufficient pedestrian signal timings and inter-green periods at a junction mean pedestrians lack adequate time to cross safely, contributing to a high number of collisions. The lengthy timescale for planned improvements was also noted.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner identified that keys to locked medication cupboards were kept in easily accessible, unlocked locations, risking service users accessing medication. There was no evidence that this practice had been changed or addressed across other similar accommodations.
Addressed to: MIRUS Wales
AI-generated concerns summaryThe ambulance service's triage system prioritised physical health over mental health risks for individuals reporting self-harm, and lacked questions about contacting others for safety checks. There was also insufficient collaboration between blue light services in Liverpool to share mental health crisis intervention resources.
Addressed to: Chief Constable; North West Ambulance Service, Director of Publish Health and Police and Crime Commissioner
AI-generated concerns summaryThe coroner noted a lack of comprehensive records for medication, especially drugs prone to misuse, in a mental health hospital. There was also no system to track what patients accessed, or fixed training for doctors regarding suspected drug overdose treatment.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identified outdated pathology guidance and inadequate sample retention in suspected anaphylaxis death investigations. Concerns also include gaps in education for doctors and patients regarding severe food allergies and a need for improved food labelling practices.
Addressed to: British Hospitality; British Retail Consortium; British Society for Allergy and Clinical Immunology; Department of Health and Social Care; Food and Drink Federation; Food Standards Agency; Royal College of Pathologists; UK Health Security Agency
AI-generated concerns summaryThe coroner identified inadequate communication with parents regarding the seriousness of the situation, a delay in administering prescribed antibiotics, and staff not using the emergency bleep system to alert the paediatric team.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner identified a lack of automatic Police National Computer checks for individuals facing prosecution by non-police authorities, which prevents firearms licensing bodies from assessing their continued suitability to possess a firearm.
Addressed to: HM Revenue and Customs
AI-generated concerns summaryThe coroner identified concerns regarding the low completion rate of essential malnutrition screening training, noting it is not mandatory for all relevant staff. Additionally, the Trust's Nutrition and Hydration Committee is inconsistently supported and attended.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a 24/7 thrombectomy service at RCHT, resulting in an estimated 75 stroke patients in Cornwall not receiving this procedure. A lack of a service level agreement with the nearest 24/7 thrombectomy service further limits treatment options.
Addressed to: NHS England; North Bristol NHS Trust
AI-generated concerns summaryThe decision not to commence CPR was not in accordance with Trust or national policy, which could impact patient outcomes.
Addressed to: Barnsley District General Hospital
AI-generated concerns summaryJoan's personal care staff were not included in or aware of her hospital risk assessments or care plans, creating a potential for care contrary to medical advice. Clarifying roles and involving these staff in care planning would improve safety.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding superficial risk assessments, a lack of a key worker approach, and insufficient communication with both the armed forces and the family. There was also anxiety among staff concerning appropriate risk sharing.
Addressed to: NHS South Yorkshire Integrated Care Board; South Yorkshire West NHS Foundation Trust
AI-generated concerns summaryThe Metropolitan Police Service's Vehicle and Equipment SOP insufficiently references the safety of other road users and pedestrians. The policy's section on 'silent approach' is also too open to interpretation regarding exceptions and its applicability to response drivers.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryEvidence indicated a delay in ambulance attendance, which likely meant the deceased would not have died when he did. The ambulance service attributed this to broader local NHS Trust capacity issues.
Addressed to: Department of Health and Social Care; The Secretary of State for Health and Social Care
AI-generated concerns summaryThe coroner noted that the International Academies of Emergency Dispatch algorithm for emergency response does not consider whether a patient is on blood-thinning medication for head injuries, raising concerns that this could lead to future deaths.
Addressed to: International Academies of Emergency Dispatch
AI-generated concerns summaryThe coroner highlights an incomplete understanding of M abscessus in hospital water systems. Health Technical Memorandum 04-01 lacks specific guidance for identifying, controlling, or testing for M abscessus, especially for immunosuppressed patients and new hospitals.
Addressed to: Department of Health and Social Care