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 summarySpringfield Health Care's poor record-keeping, communication, and failure to implement advice from external agencies meant a client continued excessive wheelchair use as a general seating option. This was contrary to specific guidance from Wheelchair Services.
Addressed to: Care Quality Commission; Springfield Health Care Services
AI-generated concerns summaryThe coroner identified concerns regarding a Consultant not following an established Vascular Pathway and poor medical-radiology communication, leading to delays. Additionally, the Trust's review was insufficiently robust regarding pathway dissemination, awareness, and staff training for rapid care escalation.
Addressed to: County Durham and Darlington NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient statistical data for evaluating police pursuit risks and effectiveness. The report notes the high burden on police drivers and managers, who operate with limited real-time information, indicating a need to refine pursuit parameters.
Addressed to: Regional Major for West Yorkshire; West Yorkshire Police
AI-generated concerns summaryThe coroner identified a failure to complete Multifactorial Risk Assessments (MFRA) for a falls risk patient, contrary to health board policy. Doubts were raised about prevention as previous action plans were ineffective, and reasons for non-adherence unknown.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryK&C hospital did not measure ferritin levels in patients receiving frequent platelet transfusions, risking undetected iron overload. The coroner noted that even without funding for chelation therapy, patients could be referred or informed of private treatment options.
Addressed to: East Kent Hospitals University NHS Foundation Trust; Kent and Canterbury Hospital
AI-generated concerns summaryThe coroner identified concerns regarding King's Hospital's paper-based paediatric early warning score (PEWS) system potentially leading to sub-optimal care. There were also concerns about the stalled programme intended to improve the formal relationship and outreach between paediatric hepatology and intensive care departments.
Addressed to: King’s College Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about a lack of action taken from previous self-harm incidents and the absence of risk alerts on patient records. Further issues included multiple breaches of the Enhanced Care Policy and insufficient implementation of recommendations, particularly regarding family involvement.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner noted that Level 3 constant observations were performed using monitor screens, meaning patients were not always directly visible, and this practice was not explicitly prohibited. There were also concerns that the process for searching patient bedrooms for prohibited items was ineffective.
Addressed to: Oxford Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that nursing staff were unaware of room monitor volume settings and their inclusion in handover checks. There was a lack of clear procedures and documentation for 'OFF COMS' alerts, which went unaddressed for several days.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe report highlights a lack of clarity regarding responsibility for discharge planning and post-discharge oversight for psychotherapy patients without a Care Coordinator, noting they are not routinely discussed in MDT meetings. Concerns were also raised about carers not consistently being involved in after-care plan reviews.
Addressed to: Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the continued occurrence of deaths from misplaced nasogastric tubes, which are 'never events', and identified a lack of a unified approach across NHS Trusts to prevent these avoidable incidents.
Addressed to: Barts Health NHS Trust; Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner raised concerns that a specific section of the A6068 frequently accumulates surface water due to inadequate drainage and road design, creating a known hazard for motorists. The report recommends significant permanent engineering alterations and the installation of warning signs to enhance road safety.
Addressed to: North Yorkshire County Council
AI-generated concerns summaryNational safeguarding guidance documents do not include childhood obesity as a sign or symptom of neglect. The coroner noted this absence is a concern, with public health experts suggesting it should be included to protect children.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted an unclear account of a resident's fall at Tamworth Court Nursing Home, with no incident recorded in nursing notes, no incident form completed, and no investigation or evidence of learning from the event.
Addressed to: Prime Life Limited
AI-generated concerns summaryThe coroner identifies gaps in applying safety measures from fire risk assessments. Concerns also include inconsistent Telecare provision for vulnerable individuals, often not linked to smoke alarms, and a lack of regular Person-Centred Risk Assessments.
Addressed to: London Borough of Brent, Network Homes Housing Association and Barnet Assist
AI-generated concerns summaryThe coroner questioned the quality and effectiveness of online first aid training, as staff appeared unable to provide aid despite recent completion. Concerns were also raised regarding the adequacy of only providing first aid training every three years for vulnerable residents.
Addressed to: Hamilton Community Homes Ltd
AI-generated concerns summaryThe coroner noted insufficient mandatory training for railway staff on vulnerable persons, an inappropriate protocol used by control room staff, and a lack of information sharing with British Transport Police and Network Rail.
Addressed to: Govia Thameslink Railway Ltd and and Network Rail
AI-generated concerns summaryThe hospital's Falls Policy does not comply with NICE Guidelines, and a planned new policy, staff training, and the appointment of a Falls Lead have all been significantly delayed. The implementation of assisted technology for patient monitoring has also not progressed.
Addressed to: Norfolk and Norwich University Hospital
AI-generated concerns summaryThe Emergency Department lacked clinical guidance for suspected aortic dissection, including a directive for ECG gated CT scans, and had no mechanism to alert staff to a patient's genetic risk of the condition.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a persistent culture of bullying and harassment within the Crisis Resolution Home Treatment Team, affecting compassion and referral recognition. There was also no immediate review or discussion of discharge decisions from the Community Team after assessment.
Addressed to: Hellesdon Hospital