Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryMr Rees was inappropriately allocated to a low-risk falls observation level, and the subsequent internal investigation (RCA) failed to identify this error. This suggests a misunderstanding of the falls policy among staff and a missed opportunity for organisational learning.
Addressed to: University Hospitals Bristol and Weston NHS Foundation Trust
AI-generated concerns summaryInsufficient resourcing and provision within mental health services for young people led to long waiting times for assessments by child psychiatrists, delaying diagnosis and treatment. The increased demand for CAMHS services without corresponding resource increases is noted as unsustainable.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryLimited weekend doctor availability meant a patient was not reviewed face-to-face despite sepsis triggers, and the trust's sepsis policy was not followed or escalated by nursing staff.
Addressed to: Department of Health and Social Care; Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe independent consultant psychiatrist lacked facilities to make assessment notes, and there was no documented agreement on the assessment outcome between professionals, causing confusion about required actions.
Addressed to: Department of Health and Social Care; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner identified a lack of robust systems for managing essential heart monitoring devices and their replacement, resulting in excessively long waiting lists. Additionally, critical outpatient letters were significantly delayed, hindering timely communication of important medical information.
Addressed to: Birmingham Women and Childrens Hospital NHS Foundation; the NHS Commissioning team
AI-generated concerns summaryThe coroner identified delays in a patient's hip fracture care, attributing them to a shortage of cardiologists, especially for weekend and out-of-hours assessments, and insufficient theatre and High Dependency Unit bed capacity at the Trust.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of a clear system and protocol for initiating the unblinding process in clinical trials, particularly when a patient is treated in another hospital. There is also no formal referral system for reporting adverse events, which impacts transparency between hospitals.
Addressed to: Medicines and Healthcare products
AI-generated concerns summaryThe coroner noted a lack of specific guidance for managing immunosuppressed patients at high risk of Covid-19 in a hospital setting, including expediting their discharge or exploring alternative treatments. There was also a need for greater monitoring of kidney function to prevent opiate toxicity.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryInformation on managing Mr. Kay's medical valve, which required regular monitoring and replacement, was not shared with his care home. There was also insufficient understanding of the specialist nurse service's role within the community, including by his GP.
Addressed to: Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner raised concerns about prolonged waits in the Emergency Department and delays to surgery for elderly patients with hip fractures due to bed and capacity shortages, leading to a lack of orthogeriatric care and non-compliance with NICE guidance.
Addressed to: Greater Manchester Health and Social Care Partnership; Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identified unclear clinical advice regarding weight-bearing status and an ambiguous hospital policy for reducing Venous Thromboembolism risk, especially for outpatients with fractures. Additionally, evidence of information provided to the patient was unavailable.
Addressed to: Wye Valley NHS Trust
AI-generated concerns summaryThe coroner noted that the coach driver did not apply emergency brakes due to training prioritising passenger welfare, despite evidence that emergency braking could have prevented the collision. Emergency braking procedures are not part of mandatory training for new bus and coach drivers.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted inadequate wound inspections and dressing changes when clinic attendance reduced, with no alternative care plan implemented. There was also no process for managing patients who decline potentially life-threatening care and likely lack capacity.
Addressed to: Kings College Hospital; QHS GP Care Home; Tower Bridge Care Home
AI-generated concerns summaryThe coroner noted a lack of requirement for direct telephone communication between police forces when tasking or transferring investigations, potentially leading to lost information and delays in effective action.
Addressed to: National Police Chiefs’ Council
AI-generated concerns summaryThe coroner identified delays in calling emergency services due to staff training gaps, an emergency call system that directed requests to distant staff, and staff lacking confidence in basic first aid. There was also no advanced first aider available on site.
Addressed to: Brunswick Retirement Village
AI-generated concerns summaryThe coroner identified limitations in the 111 algorithm regarding the assessment of parental concern, prior GP review, and timing of advice requests for paediatric referrals. Additionally, the report notes a need for professional bodies to disseminate information on rare conditions and endorse 111 as a definitive safety net.
Addressed to: NHS Digital; NHS Pathways; Royal College of General Practitioners; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner identified inadequate and unclear signage warning visitors of the risk of drowning at Sgwd Gwladys. There were also concerns about the unclear responsibility for the area due to multiple overlapping local authority and environmental jurisdictions.
Addressed to: Brecon Beacons National Park Authority; Natural Resources Wales; Neath Port Talbot Council; Powys County Council; Rhondda Cynon Taff County Borough Council
AI-generated concerns summaryThe coroner identified issues with the recording and sharing of crucial information for risk assessments, noting a lack of a system to ensure consistency between two assessment types and that a previous incident was not clearly recorded, potentially affecting care decisions.
Addressed to: Devon Partnership NHS Trust
AI-generated concerns summaryConcerns were raised regarding the council's landlord licensing regime, as licenses are granted without prior premises audits and property assessments omit explicit child safety risks. The report also notes insufficient clarity on enforcement actions and tenant information.
Addressed to: Oldham Council
AI-generated concerns summaryThe coroner noted inadequate signage for a temporary 30 mph speed limit, as existing 50 mph signs were not obscured, potentially leading road users to be unaware of the reduced speed.
Addressed to: Kier Highways Ltd; Suffolk Highways