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 that patient literature for methotrexate did not include phototoxicity as a rare side effect, and it was unclear whether this literature would be reviewed after a Yellow Card report.
Addressed to: NHS England; NHS Improvement
AI-generated concerns summaryA discrepancy in opioid prescription for an inpatient was not reviewed due to a lack of alerts on the electronic system. Additionally, the standard of medical record-keeping was poor, with insufficient documentation of decision-making and discussions.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe coroner identified outdated guidance and risk assessment tools for damp and mould in housing, noting insufficient accessible health information for the sector. Concerns were also raised about housing associations' practice of delaying repairs during disrepair claims.
Addressed to: Department of Health and Social Care; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner identified gaps in post-discharge care for a 91-year-old man, including no arranged follow-up and the rejection of a GP referral for district nurse support. There was also no system for automatic follow-up of patients discharged home requiring care.
Addressed to: Milton Keynes University Hospital and Central North West London NHS Trust
AI-generated concerns summaryThe coroner noted inadequate fluid intake for the resident, especially during a heatwave and in the days before death. Concerns were also raised about inadequate record keeping and the absence of a manager at the care home for three days prior to the death.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner identified difficulties accessing emergency services for a disabled patient in severe pain, as 999 responders indicated no resources and deemed her not a priority. There were also concerns regarding the out-of-hours GP service's ability to expedite care or provide pain relief.
Addressed to: Cardiff and Vale University Health Board; Welsh Ambulance Service NHS Trust
AI-generated concerns summaryConcerns were raised regarding an avoidable fatal fall by a high-risk patient, the subsequent four-day delay in obtaining a CT head scan, and the prescription of blood thinning medication without knowing the extent of intra-cranial damage.
Addressed to: Department of Health and Social Care; Royal London Hospital
AI-generated concerns summaryThe coroner identified a lack of emergency access protocols for consular officers to reach detained British nationals and insufficient information in FCDO travel advice about detention consequences in Dubai. Concerns were also raised about procedures for accessing British nationals in mental health crisis who cannot provide consent.
Addressed to: Department for Foreign, Commonwealth and Development Affairs
AI-generated concerns summaryThe coroner raised concerns about delays in increasing intermediate care bed capacity and the need for mitigation strategies. Issues included discharging medically fit patients to overwhelmed primary care services or residential homes with insufficient staffing, risking re-admission.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of multi-agency working and information sharing during an emergency housing move, and a 2-3 week backlog in an NHS referral service where GPs were not informed of capacity issues.
Addressed to: Bromley Council; Clarion Housing Group; Oxleas NHS Foundation Trust
AI-generated concerns summaryConcerns were raised about a 12-hour delay in medical review and escalation after malaena was noted, and that anti-coagulation therapy was not withheld. The late disclosure of the 72-hour care review also impacted inquest preparation for the family and coroner.
Addressed to: Whittington Health NHS Trust
AI-generated concerns summaryThe coroner noted that a patient exhibiting persistent severe mental health symptoms and requesting admission received no formal diagnosis nor escalation in management or admission.
Addressed to: Avon and Wiltshire Mental Health Trust
AI-generated concerns summaryThe coroner noted a lack of clear documentation regarding required disability adjustments for the prisoner and insufficient disability awareness among prison staff.
Addressed to: HMP Belmarsh; Oxleas NHS Trust
AI-generated concerns summaryConcerns were raised about a misreported CT C-spine scan, a reviewing surgeon's failure to note or escalate an abnormality, and the neurosurgical team not reviewing images before surgery. This was compounded by repeated communication failures between clinical teams and poorly maintained clinical records.
Addressed to: Barking, Havering and Redbridge NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted an absence of mandatory training for academic staff in suicide prevention and mental health awareness. Concerns included the university's reactive, email-based approach to student welfare and a lack of staff understanding regarding information sharing policies with families.
Addressed to: Exeter University
AI-generated concerns summaryThe coroner noted severe understaffing in the domestic abuse team within the Public Protection Unit, which resulted in cases not being investigated and left victims of domestic violence at serious risk.
Addressed to: Home Office; West Midlands Police
AI-generated concerns summarySignificant emergency department waiting times due to high patient volumes led to delayed treatment. There was no recognised way for community and hospital clinicians to share vital information, and staff lacked awareness of neutropenic sepsis guidance, delaying appropriate treatment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted significant ambulance delays exceeding 5 hours due to high demand and staff shortages. Additionally, difficulties accessing cardiac tests at District General Hospitals out of hours caused surgical delays for patients with fractured neck of femur, inconsistent with NICE guidance.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of widespread understanding and promotion of effective FIT tests for early bowel cancer detection. Concerns were also raised about the challenges for GPs in interpreting high volumes of haemoglobin test results.
Addressed to: Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner identified concerns regarding the lack of routine SALT assessments for care home residents who stop using dentures, which can lead to unadjusted diets. Limited access to dental services delays denture replacements, and care homes do not routinely have suction machines to assist during choking incidents.
Addressed to: Greater Manchester Health and Social Care Partnership