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 noted a national shortage of mental health beds, causing delays for patients in acute hospitals awaiting transfer. Significant staffing challenges on mental health wards also required redeploying staff and using agency personnel.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of clear national protocols to ensure all NHS Trusts prevent language barriers from impeding access to treatment, despite local improvements by the Trust in question.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted ongoing delays in North West Ambulance Service attending Category 2 calls due to staff and vehicle shortages. Furthermore, ambulance resources are underutilised because of handover delays at A&E departments, stemming from wider NHS pressures.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted relatively little information is available about more unusual ways fentanyl can be misused or abused, raising concern about future deaths if action is not taken.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted a patient's care level was downgraded without following trust policy, and an audit to check broader compliance with this policy had been significantly delayed.
Addressed to: Birmingham and Solihull Mental Health Foundation Trust
AI-generated concerns summaryStaff lacked competence in fire evacuation, and specialist housing fire alarms did not automatically alert emergency services. The coroner noted insufficient fire safety audits and a lack of clear guidance on managing high-risk electrical devices and digital locks.
Addressed to: British Standards Institution; London Fire Brigade; National Fire Chiefs’ Council; Sequence Care Group
AI-generated concerns summaryDelayed delivery and inadequate fetal heart rate monitoring arose from a midwife being discouraged from performing an episiotomy. Concerns were also raised about insufficient patient consultation on birthing options and potentially influencing language in birth documentation.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding inadequate documentation of a senior clinician's treatment plan and a doctor's assessment of nursing concerns. There was also insufficient communication regarding prescribed anti-embolic stockings to nursing staff.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe coroner noted parents were not informed of a consultant's review plan and found no evidence of how the unit accesses wider regional specialist support. Questions were also raised about the extensive detail of documentation forms and the potential impact of the staffing structure.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in statutory notifications of incidents to the CQC, including one that was never reported, potentially hindering investigations. Concerns were also raised regarding poor record-keeping at the care home, where care notes did not accurately reflect residents' needs and care plans were not updated.
Addressed to: Baedling Manor Care Home
AI-generated concerns summaryThe coroner noted insufficient staffing levels, particularly for a resident requiring one-to-one care, and raised repeated concerns about the poor standard of record-keeping at the care home, which did not accurately reflect resident needs or incidents.
Addressed to: Alcyone Healthcare; Baedling Manor Care Home
AI-generated concerns summaryThe coroner noted the mental health service wrongly attributed Emotionally Unstable Personality Disorder to an autistic individual, causing distress and a breakdown of trust. This included a misunderstanding of autism, underdeveloped provisions for autistic conditions, and a lack of adapted psychological therapy and coordinated care within the service.
Addressed to: Minister of State for Care and Mental Health; NHS England & NHS Improvement; North Yorkshire Clinical Commissioning Group; Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues at the Priory Hospital with record-keeping accuracy and the timely updating of risk assessments. Concerns were also raised regarding the failure to learn from previous incidents to improve courtyard fence safety and the absence of national guidelines for perimeter security in mental health units.
Addressed to: Department of Health and Social Care; Priory Group
AI-generated concerns summaryThe coroner noted a lack of specific guidelines for the optimal management of fetal infection, which can be fatal, unlike the existing guidelines focusing on maternal infection. Clinicians and an expert agreed that such guidelines would be beneficial.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted a lack of recorded escalation for high NEWS2 scores and abnormal vital signs, along with incomplete vital sign documentation. Concerns were also raised regarding the sufficiency and staff understanding of policies for taking, recording, and escalating observations at the hospital.
Addressed to: Holy Cross Hospital
AI-generated concerns summaryThe coroner noted inadequate clinical record keeping, risk assessments, and mental state examinations. Issues were also raised regarding the discharge of a vulnerable patient lacking appropriate community support and the absence of a safeguarding referral.
Addressed to: GMMH NHS Trust
AI-generated concerns summaryAdvance Nurse Practitioners did not routinely review medication regimes or access medication charts for elderly care home patients during visits, leading to multiple missed opportunities to correct a critical treatment error.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted a delay in escalating the incident, resulting in a four-hour response delay. There were also concerns about the availability of method of entry kits and the need for improved document management.
Addressed to: Greater Manchester Police; Independent Office for Police Conduct
AI-generated concerns summaryThe coroner identified insufficient ward staffing, a duty psychiatric doctor not attending to assess the patient when requested, and the patient receiving an item contrary to a clear instruction. Further concerns included inadequate record-keeping and a lack of follow-up on risk assessments and patient observations.
Addressed to: Hellesdon Hospital
AI-generated concerns summaryThe coroner identified legislative gaps preventing agencies from mandating an Event Organiser or prohibiting events with significant public safety risks. This results in no single contact for public safety at events, with national implications.
Addressed to: Minister for Crime and Policing