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 telecare service was not reviewed despite a patient's increased fire risk and deteriorating mobility. A smoke alarm not connected to the telecare system delayed emergency services for a vulnerable person living alone.
Addressed to: CECOPS; Care Quality Commission; Department of Health and Social Care; Telecare Services Association; Home Office; UK Telehealthcare
AI-generated concerns summaryThe coroner noted the absence of a clear, detailed handover or transfer document from Ilkeston Community Hospital to Royal Derby Hospital, and that Royal Derby Hospital did not request this crucial document. This omission prevented the implementation of enhanced care and observation to prevent falls.
Addressed to: Ilkeston Community Hospital; University Hospitals of Derby and Burton
AI-generated concerns summaryThe coroner noted that inexperienced junior doctors primarily provided medical care and assessed deteriorating patients without easy access to senior input, and blood test results were not reviewed in a timely manner.
Addressed to: Nottingham University Hospital NHS Trust
AI-generated concerns summaryThe coroner identified insufficient physical safety measures on the bridge, a lack of emergency help points or mental health support signage, and no monitored CCTV. This is despite a high number of crisis incidents at the recognised danger spot.
Addressed to: Hampshire Highways; Highways England
AI-generated concerns summaryThe coroner noted recurring concerns about the high risk to prisoners in the early days of custody at HMP Swansea, especially for new arrivals. Additionally, key prison staff were not interviewed or debriefed immediately after a death, which hampered the investigation and learning.
Addressed to: HMP Swansea
AI-generated concerns summaryAssessments for individuals with severe and multiple disadvantage are undertaken by staff without specialist training, leading to inaccurate plans. Care Act assessments are not consistently extended to consider changed care needs when a person moves to different accommodation.
Addressed to: Nottingham City Council
AI-generated concerns summaryThe coroner identified issues with the drainage gully inspection system, as blocked gullies were not identified in a recent check. A lack of explanation for significant standing water on the carriageway means the highway remains at risk of future water ingress.
Addressed to: North Lincolnshire Council
AI-generated concerns summaryThe coroner noted that a lethal substance is freely available online in the UK in lethal quantities, and there is no protection for vulnerable people making such purchases.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of required written confirmation for falls risk handovers between wards, along with concerns about the six-hour target for falls risk assessments for vulnerable patients and inconsistent use of visual risk indicators on beds.
Addressed to: Stockport NHS Foundation trust
AI-generated concerns summaryThe coroner noted Surrey County Council’s lack of reflection and documented changes to pothole management following Mr Stringer’s death. Concerns include insufficient action on informing inspectors of complaints, robust risk assessments, timely communication between departments, and prompt repairs.
Addressed to: Surrey County Council, Highways Agency and Kier Integrated Services
AI-generated concerns summaryThe coroner raised concerns that the MHRA lacks the power to compel timely production of relevant clinical data, which affects its ability to conduct robust safety investigations.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of age verification and age-specific content on online platforms, along with no separation between adult and child parts of platforms. Concerns were also raised about algorithms providing content and adverts, and the absence of parental control or access to material viewed by children.
Addressed to: Baker & McKenzie LLP; Department for Digital, Culture, Media & Sport; Meta Platforms; House of Commons; Pintrest; RPC; Snap Inc; Twitter International Company
AI-generated concerns summaryThe GP practice lacked a process to ensure a full review by a GP before issuing further prescriptions after a patient had overdosed on prescribed medication.
Addressed to: Heathview Medical Practice; NHS England; NHS Registrations
AI-generated concerns summaryThe coroner identified a need for policies and training that help professionals identify individuals "masking" mental illness, noting a perception that professionals often accept self-reported information without sufficiently considering family evidence.
Addressed to: Vine Street Surgery and LPFT Legal Services and Legal Services Lincolnshire
AI-generated concerns summaryThe coroner identified a lack of proper assessment of locum doctors' skills and insufficient supervision, noting that locums were deployed without clear procedures for competence checks or consultant oversight, particularly for out-of-hours care.
Addressed to: Department of Health and Social Care, NHS England, East Kent Hospital NHS Foundation Trust, The Royal College of Obstetricians and Gynaecologists, CQC and General Medical Council; The Chief Coroner
AI-generated concerns summaryDemand for ambulance services consistently outstrips supply, leading to response times significantly exceeding targets. This issue is attributed to wider resource limitations across primary, secondary, and social care, causing ambulance backlogs at A&E departments.
Addressed to: Department of Health and Social Care, NHS England and Association of Ambulance
AI-generated concerns summaryThe coroner noted a gap in the management of Protein S deficiency, as patients are diagnosed but not adequately informed about how other risk factors or life events might exacerbate their condition. This lack of information and surveillance places patients at potential hazard.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner noted that the patient was discharged from the hospital with indicators of infection before blood test results were available, which was contrary to best practice.
Addressed to: Royal Wolverhampton NHS Trust
AI-generated concerns summaryThe coroner identified that the Patient Safety Investigation (PSI) report following Mr. Elliott's death overlooked obvious failings in his care, specifically regarding inadequate falls risk assessments and their management. This resulted in missed opportunities for the Trust to learn and enhance patient safety.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryThe coroner identified that diabetic patients with stable glucose levels do not have pre-issued rapid-acting insulin prescriptions, which can lead to significant delays in treatment if their levels rise. This lack of standby provision for bolus injections increases the risk of hyperglycaemic collapse.
Addressed to: Executive NHS Leicester; Leicestershire and Rutland Integrated Care Board