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 noted that the categorisation of potholes in East Sussex, particularly the definition for Cat 3 - LOW risk, requires significant review to prevent future avoidable deaths.
Addressed to: East Sussex County Council
AI-generated concerns summaryThe coroner noted a lack of official Trust guidance on managing VITT, which led to delays in transferring the patient to a specialist centre and contacting appropriate consultants, despite national and regional guidance being available.
Addressed to: Worcestershire Acute Hospitals NHS trust
AI-generated concerns summaryThe mental health service faces demand for direct referrals that significantly exceeds its capacity, leading to insufficient resources to meet service obligations and creating an increased risk for individuals requiring care.
Addressed to: NHS England; West London Mental Health NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding the insufficient involvement of family members/carers in the mental health risk assessment process and their awareness of care decisions. There was also an absence of clear criteria for conducting Carer's Assessments early with the Home Treatment Team.
Addressed to: Somerset NHS Foundation Trust
AI-generated concerns summaryThe coroner highlighted the absence of a regional system for sharing radiology images between West London hospitals, which hinders image comparison and increases clinician workload, with potential for missed diagnoses and adverse patient outcomes.
Addressed to: Kingston Hospital NHS Trust; NHS England
AI-generated concerns summaryThe WARRN assessment tool did not optimally record fluctuations in self-harm risk, making it difficult for new or infrequent users to access clear, up-to-date information, potentially leading to under-estimation of current risk. The tool could also benefit from greater user interaction, such as prompts for referrals.
Addressed to: Powys County Council; Powys Teaching Health Board
AI-generated concerns summaryThe coroner identified a lack of clear national emergency guidelines for managing choking incidents in overweight or obese individuals where conventional abdominal thrusts are ineffective. The report suggests reviewing alternative techniques, such as inversion, and specialist equipment for these circumstances.
Addressed to: NHS England; Resuscitation Council UK
AI-generated concerns summaryThe coroner noted the ambiguity surrounding why the vehicle crossed the highway centre, making it unclear if the driver intended to exit a junction or misinterpreted the road layout.
Addressed to: Highways and Transport and Wiltshire Council
AI-generated concerns summaryThe Derbyshire Red Bag scheme, designed to transfer care home resident information to hospital, is not widely used. There is insufficient awareness among staff on how to use the bag, resulting in vital patient information not being consistently accessed.
Addressed to: Derbyshire County Council and NHS Derby & Derbyshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted concerns regarding the inadequate care plan for Louise Allen, identifying a lack of continuity of care due to insufficient care co-ordinators, high staff turnover, excessive caseloads, and recruitment challenges within the Trust.
Addressed to: London Borough of Waltham Forest; North East London Health and Car; North East London Health and Care Partnership; TNW Integrated Care Partnership; North East London NHS Foundation Trust and The Clinical Commissioning Group
AI-generated concerns summaryUpon arrival at a mental health ward, a patient's falls risk assessment was not undertaken, leading to a fall while unsupervised the following day.
Addressed to: Department of Health and Social Care; Department of Health and Social Care and East London Foundation NHS Trust
AI-generated concerns summaryThe coroner identified ongoing delays in accessing out-of-hours second doctors for Mental Health Act (MHA) assessments. There are also difficulties securing timely private ambulance transport for patients after MHA assessments, potentially increasing risk.
Addressed to: NHS England; NHS England and NHS Tees Valley Clinical Commissioning Group; NHS Tees Valley Clinical Commissioning Group
AI-generated concerns summaryThe provided text outlines the patient's medical course and the narrative conclusion of the inquest, but does not detail specific coroner's concerns for future death prevention.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified gaps in emergency 'code blue' response, the absence of a central record for cell fabric history at HMP Birmingham, and a lack of formalised visual inspection of all healthcare cells by the mental health trust.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust; Ministry of Justice
AI-generated concerns summaryThe coroner noted significant delays in ambulance response due to resource allocation and considerable handover delays at hospital sites, posing a risk of future deaths for patients needing emergency care.
Addressed to: Welsh Ambulance NHS Foundation Trust and Betsi Cadwaladr University Local Health Board
AI-generated concerns summaryDelays in conducting X-rays were identified due to busy Emergency Departments preventing ambulance offloads. The report also noted a lack of a clear escalation process to ensure X-rays are completed when not initially carried out.
Addressed to: Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
AI-generated concerns summaryThe coroner noted there is no policy for communication between KMPT and Kent County Council AMHP service regarding Mental Health Act applications, which could lead to delays for patients.
Addressed to: Kent and Medway NHS Social Care Partnership Trust and Kent County Council – Adult Social Care
AI-generated concerns summaryAlarms on ICU patient monitors were disengaged, meaning staff were not alerted when the patient's oxygen saturations fell, resulting in cardiac arrest. The coroner recommends staff be reminded of the need for alarms to remain active.
Addressed to: Milton Keynes University Hospital NHS Foundation Trust; Secretary of State for Transport
AI-generated concerns summaryThe coroner identified that trains were not advised to proceed with caution by the signals controller when travelling through the area.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified insufficient training for the Domestic Abuse Team on amended policies and procedures, including specific required training for a key officer. There were also gaps in the supervisory system to ensure timely implementation of safeguarding and investigation plans by officers.
Addressed to: National Police Chiefs’ Council; Surrey Police