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 report identified that MFT's sepsis protocols may not be up to date and that staff, including new and agency personnel, lack sufficient familiarity and training. The coroner also noted the need for periodic audits of sepsis recognition and timely treatment.
Addressed to: North Manchester General Hospital
AI-generated concerns summaryThe coroner identified concerns regarding the unrestricted public purchase of gas canisters and the absence of licensing. Additionally, a lack of colour coding for cylinders to assist emergency services was noted, along with questions about safety labelling clarity.
Addressed to: Home Office; Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner noted concerns regarding Mr Lloyd's lack of ready access to a local dual-diagnosis service, which would have offered a unified approach to his co-existing mental health and substance misuse issues.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted significant delays in ambulance response times for a Category 2 call due to high demand, which led to the patient's deterioration. Concerns remain that future deaths could occur before new measures to address these delays prove effective.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryThe coroner noted an incorrect pathway for an urgent 999 call and delays in ambulance response due to high demand. Concerns remain about future deaths while East of England Ambulance Service measures to address delays are implemented over the next year.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryThe coroner noted that the hospital's draft transfer policy did not adequately address the needs of high-risk mental health patients or ensure consultation with specialist staff during transfers. There was also insufficient staff training and understanding regarding the application of the Mental Capacity Act for patients deemed to lack capacity …
Addressed to: Bedford Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about inadequate staffing levels across CAMHS services, specifically noting a shortage of doctors, psychiatrists, and nurses. This resulted in consultant caseloads substantially exceeding recommended levels, posing a risk of future deaths among young people.
Addressed to: Royal College of Paediatrics & Child Health NHS England, Health Education England and Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted significant delays in the transfer of patient notes between general practitioners, with one instance taking 11 months, and current transfers still averaging 16 weeks. This delay risks important medical history being missed, particularly if a patient cannot communicate effectively.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that patient observations were not conducted in line with policy, with staff lacking training and clear allocation of responsibilities. Further concerns included insufficient record keeping for clinical decisions and care plans, and unclear processes for staff safety when entering rooms and for ensuring physical health checks.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an inadequate diagnostic review process, a lack of professional curiosity in verifying reported incidents, and an insufficient capacity assessment limiting information sharing with family. Additionally, the absence of debriefs after self-harm attempts impacted future risk assessments.
Addressed to: Cygnet Health Care; NHS England
AI-generated concerns summaryThe coroner noted delays in initiating CPR and that staff were unfamiliar with the crash call system. Concerns were also raised about insufficient oversight of bank and agency staff training for emergency procedures, and issues with the serious incident investigation process.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns that the Trust did not formally refer a doctor, who admitted taking medicines to end his life, to the Police or GMC. There was also a lack of meaningful external or multi-disciplinary review of the incident.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the Home Treatment Team did not speak to Ms Regan's sons to explore the need for inpatient admission as required by clinical guidance, and a care plan was not properly recorded or communicated to them.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted significant backlogs in neurology appointments due to clinician shortages, incompatible IT systems hindering inter-hospital information sharing, and communication delays from consultants because of insufficient administrative support.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner notes an absence of written policy or guidance at Sidney Gale House Residential Home for reviewing care plans after an incident, which could lead to inadequate risk assessments.
Addressed to: Tricuro
AI-generated concerns summaryThe coroner noted delays of 15 days in doctors reviewing crucial blood test results and consulting a gastroenterologist, which impacted the patient's liver biopsy and the timely commencement of steroid therapy and transplant referral.
Addressed to: Princess Royal Hospital
AI-generated concerns summaryThe coroner identified that staff did not adequately recognise choking risks for adults with autism and learning disabilities. Improved training for staff and managers on choking risks and adherence to mealtime recommendations is needed.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about post-tour debriefing for serving personnel, which lacks 1-to-1 sessions. There is also no mandatory mental health assessment during the Army resettlement process for those leaving service.
Addressed to: Military of Defence
AI-generated concerns summaryThe protocol for transferring command and control of police pursuits between Greater Manchester Police and the North West Motorway Policing Group did not operate effectively, leading to a lack of clear command during the pursuit.
Addressed to: Greater Manchester Police and Roads and Crime Unit and Response
AI-generated concerns summaryThe coroner identified gaps in the surgery's policy regarding the prescription of medication to patients with excessive alcohol consumption, and noted insufficient documentation of discussions with the patient about potential risks. Guidance is also needed for prescribing when a patient is not seen face-to-face.
Addressed to: Swanage Medical Practice