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 identified basic errors in the Root Cause Analysis investigation of a patient's fall, which limited learning and did not fully examine issues like call-bell functionality or delays in specialist advice. The initial 'moderate' harm grading of the fall was also not revisited, affecting the investigation's thoroughness.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe care home lacked a documented system to restrict residents' access to items and staff awareness of isolation's impact on elderly mental health was insufficient. Gaps in information transfer about the resident's suicide risk were also noted.
Addressed to: Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited
AI-generated concerns summaryThe coroner raised concerns that the investigation into a General Practitioner not reading a patient alert was inadequate, failing to conform to the usual detail and format of such inquiries.
Addressed to: Air Balloon Surgery; Care Quality Commission
AI-generated concerns summaryThe coroner questioned if midwifery training sufficiently embeds the priority of immediately calling an ambulance when meconium is present during a home birth. The coroner also highlighted the vital importance of retaining and examining the placenta for learning from such cases.
Addressed to: Royal Berkshire NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inadequate ACCT training at HMP Swansea, leading to a lack of understanding among prison officers about warning markers that require opening an ACCT. This creates a risk due to infrequent training and inconsistent interpretation of mandatory policy guidance.
Addressed to: HMP Swansea, Ministry of Justice and Swansea Bay University Health Board
AI-generated concerns summaryThe coroner noted a lack of systematic review and individual care plans for patients on repeat multiple analgesics within general practice, alongside difficulties in accessing specialist pain clinics due to long waiting lists. Concerns were also raised regarding GP practices not universally engaging practice pharmacists for patients with complex analgesia …
Addressed to: Department of Health and Social Care; Donneybrook Medical Centre
AI-generated concerns summaryThe coroner highlighted insufficient collaborative working between the hospital discharge team and external agencies, leading to a discharge to unsuitable accommodation and a lack of involvement or notification for key partners.
Addressed to: Wigan Discharge Team
AI-generated concerns summaryThe ambulance categorisation process for elderly patients does not fully consider the risks of a long lie, and significant delays in ambulance arrival for Amber 2 calls can contribute to adverse outcomes.
Addressed to: Wales Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted that ambulance crew availability is compromised by significant delays at hospitals for patient handovers, leading to reduced response times and creating a risk to life.
Addressed to: Birmingham Integrated Care Board and NHS England and Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a need for national guidance on tonsillectomy referrals, particularly for urgent choking cases, and noted concerns about reassessment delays due to staff leave and communication gaps between providers. Concerns were also raised regarding Bourne Leisure Ltd's lack of a national health and safety management system and robust …
Addressed to: Bourne Leisure Ltd; Brighton and Sussex University Hospitals NHS Trust; East Sussex Healthcare NHS Trust; NHS England; ENT UK
AI-generated concerns summaryRemedial works recommended for trees aligning Sailors Creek had not been carried out, despite the clear risks this posed to individuals.
Addressed to: Cornwall Council and Mylor Parish Council and Sailors Creek CIC
AI-generated concerns summaryThere was a delay in initiating the missing persons protocol, and some staff were not aware of the requirement to commence procedures immediately for informal patients, creating a risk of future delays.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that DNA CPR protocols were not followed and highlighted significant delays in accessing specialist pain clinics. Concerns were also raised about insufficient monitoring of kidney function when prescribing pain medication, increasing the risk of overdose.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryAmbulance service resource constraints caused delays and the dispatch of a private ambulance unequipped for cardiac patients. The call handling algorithm also lacked prompts to explore critical patient comments, and a disconnected call from a lone patient did not automatically escalate.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryClinicians at Ty Llidiard lacked access to the patient's community care records upon admission. The unit's clinical records were not consistently contemporaneous or integrated into a single system, which impaired proper patient assessment and safeguarding.
Addressed to: Cwm Taf Morgannwg University Health Board
AI-generated concerns summaryThe coroner identified concerns regarding PC's fitness to serve, highlighting dismissive comments about an individual's distress and the officer's failure to acknowledge an inadequate risk assessment. No evidence of post-incident supervision or training was presented to address these attitudinal deficits.
Addressed to: Independent Office for Police Conduct; Metropolitan Police Service; The Royal College of Emergency Medicine; Secretary of State for Health and Social Care, The Depa
AI-generated concerns summaryThe coroner identified under-resourcing of older age psychiatric teams, leading to a lack of trained staff and difficult access to community mental health services. This results in mental health concerns being overlooked at the end of life.
Addressed to: Department of Health and Social Care; National Quality Board
AI-generated concerns summaryThe NHS Pathways triage system does not adequately account for patients with learning disabilities, lacking specific procedures to ensure accurate symptom communication and appropriate triage. This gap risks delays in care, particularly for callers without a carer to assist.
Addressed to: Department of Health and Social Care; NHS Digital
AI-generated concerns summaryThe coroner noted failures in mental capacity assessments, medical information sharing, and escalation of vital signs at Shrewsbury Court Independent Hospital. There is concern that similar practices may exist at Iden Manor Nursing Home, operated by the same group.
Addressed to: Iden Manor Nursing Home; Whitepost healthcare Group
AI-generated concerns summaryThe coroner noted inadequate record-keeping for a resident's deteriorating condition, including missing observation results and unclear advanced care planning. There were also concerns about insufficient mobile recording devices and a lack of clear ownership and accountability for resident care.
Addressed to: Downham Grange Care Home; KINGSLEY CARE HOMES LIMITED