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 coroner raised concerns about the Trust's serious incident investigation having flawed methodology that limited learning. Additionally, insufficient support and a lack of a robust mentoring system were identified for newly appointed obstetric consultants managing complex emergencies.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe patient's GP medical record was not updated to reflect a previous overdose attempt, which meant a GP later prescribed a large quantity of medication without being aware of this history.
Addressed to: Green Porch Medical Centre
AI-generated concerns summaryThe coroner noted restricted visibility for cyclists and pedestrians exiting Woods Lake West onto Higher Drive due to fencing, and the absence of measures to ensure users slow down before entering the main road.
Addressed to: Suffolk Highways
AI-generated concerns summaryThe coroner identified insufficient staff knowledge and training on synthetic cannabinoid dangers in mental health settings. Additionally, the system for assessing risks during s.17 leave was inadequate, as escorting staff lacked access to vital patient information.
Addressed to: East London NHS Foundation Trust; NHS England; NHS Improvement
AI-generated concerns summaryConcerns relate to a large blind spot in the Mercedes Vario Box Van's design, potentially obscuring pedestrians during right turns, and the absence of front-facing audible impact sensors. Driver appraisals also did not inform drivers of failed areas or offer refresher training.
Addressed to: Mercedes-Benz; UPS
AI-generated concerns summaryThere is no policy or guidance for encouraging multi-agency meetings to share information about released IPP offenders with complex needs, particularly when agencies lack access to shared record systems.
Addressed to: Ministry of Justice; NHS England
AI-generated concerns summaryThe coroner identified a lack of communication between community psychiatric and neurology teams across England and Wales, alongside under-resourced epilepsy services, particularly insufficient nursing staff. The report also noted a need for improved police training on epilepsy and complex mental health conditions when dealing with missing persons.
Addressed to: Association of British Neurologist; BCP Council; Department of Health and Social Care; Dorset County Council; Dorset Healthcare University NHS Foundation Trust; Dorset Police; NHS Dorset; Royal College of Psychiatrists; College of Policing
AI-generated concerns summaryThe coroner noted a lack of national guidance on feeding expectations for low-risk formula-fed babies in their first 72 hours, which could result in premature discharge and families lacking crucial information on warning signs.
Addressed to: National Institute for Health and Care Excellence; Royal College of Midwives
AI-generated concerns summaryThe coroner noted that a device forming a ligature point was present in cells on the healthcare wing, including the one where Mr Tamiem died, despite "safer cells" being designed to remove such points. There were no plans to address this identified risk.
Addressed to: HMP Bedford; HMPPS
AI-generated concerns summaryThe coroner noted a lack of written policies for care planning and risk assessments, with concerns that reviews were either not completed or records were falsified. Additionally, family members were not always given timely information about significant incidents or deprivation of liberty.
Addressed to: Radcliffe Manor House Care Home
AI-generated concerns summaryThe coroner identified that the Trust lacked a registry for monitoring and recalling patients with stents, hindering risk assessment for older implants. The death was also not escalated as a serious incident through governance procedures until raised by the coroner.
Addressed to: Royal College of Surgeons; Department of Health and Social Care; Barking, Havering and Redbridge University Hospitals NHS Trust; British Association of Urological Surgeons
AI-generated concerns summaryThe coroner identified inadequate specialist consultation for Stevens-Johnson Syndrome, excessive delays in A&E assessment and escalation of critical blood results, and a lack of urgency in treatment on the medical ward.
Addressed to: North Cumbria Integrated Care Trust
AI-generated concerns summaryThe coroner noted concerns regarding a significant ambulance delay, which necessitated the patient's family transporting him to the hospital themselves, causing the patient distress and discomfort.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the significant burden of responsibility placed on individual Care Coordinators, whose role lacks consistent job descriptions across Trusts. Limited resources in Community Mental Health Teams mean no cover is available during a Care Coordinator's absence.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe Priory had inadequate garden fence security, and national guidance for 'locked ward' perimeter fencing was absent. Insufficient information exchange at handovers, with uncompleted forms, hindered recognition of emerging behaviour.
Addressed to: Department of Health and Social Care; Priory Group
AI-generated concerns summaryAn abnormal X-ray report identifying a fracture was not acted upon, resulting in Mrs Stewart missing indicated follow-up care. The Trust also did not investigate why this occurred, preventing identification of broader issues or learning from the incident.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summarySignificant demands on the District Nursing Team impacted community catheter care, while Mr. Jones's learning difficulties were not fully recognised in hospital, affecting necessary support and IMCA provision. A local authority dispute over catheter care training also hindered respite care.
Addressed to: Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner identified issues with the Crisis Recovery and Home Treatment Team's manual action tracking, where incomplete tasks were marked as done. Concerns included the lack of a clear re-entry pathway and communication gaps for vulnerable patients discharged from mental health services.
Addressed to: Hywel Dda University Health Board
AI-generated concerns summaryThe coroner noted delays by the carer in identifying the deceased was unconscious and summoning medical assistance, indicating a lack of training and skills in responding to medical emergencies.
Addressed to: Berkeley Home Health
AI-generated concerns summaryThe coroner identified a gap in support for vulnerable individuals with suicidal ideation who were not deemed to have an acute mental illness, leading to them being passed between agencies without lasting benefit.
Addressed to: Department of Health and Social Care; South West Yorkshire Partnership NHS Foundation Trust