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 highlighted the need for improved documentation to demonstrate reviews of resident risk assessments following falls and for a timely process to complete these reviews at Blenheim House.
Addressed to: Blenheim House Care Home
AI-generated concerns summaryThe coroner noted that an external heat source could easily create a flammable environment by evaporating volatile substances, which should not have been present within the pontoon.
Addressed to: EKO-INVEST, POM-EKO and EURO-EKO
AI-generated concerns summaryThe coroner noted the absence of a formal preoperative risk assessment tool and poor communication between surgical and anaesthetic teams. There were also concerns regarding a senior consultant leaving surgery early without effective communication or a system to monitor this.
Addressed to: Department of Health and Social Care; Royal College of Anaesthetists; Royal College of Surgeons; Royal London Hospital
AI-generated concerns summaryThe coroner identified a lack of written policy within the Trust for granting group leave from mental health units, including no mandatory risk assessment criteria or guidelines for staff-to-patient ratios during leave.
Addressed to: Lancashire and South Cumbria NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a failure to assess Mrs. Toye for malnutrition risk using the MUST score system, with an incorrect score recorded in her notes preventing further action. Audits revealed that one in ten patients on the ward were not being assessed for malnutrition risks.
Addressed to: Department of Health and Social Care; Royal London Hospital
AI-generated concerns summaryThe coroner raised concerns about the awareness of immersion pulmonary oedema risks in diving, the need for "fitness to dive" medical certificates, and the efficiency of diver removal techniques at diving centres.
Addressed to: British Diving Safety Group; National Diving and Activity Centre; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that an interpretation of the Mental Health Act 1983 Code of Practice led to individuals detained under Section 136 being discharged without an Approved Mental Health Professional assessment. This practice was noted as contravening the Act and exposing patients to risk.
Addressed to: Association of Directors of Adult Social Services; Department of Health and Social Care; East London NHS Foundation Trust; Health and Housing – Central Bedfordshire; Royal College of Psychiatrists
AI-generated concerns summaryConcerns were raised about medication management at HMP Usk, where prisoners self-manage drugs that are not securely stored. This contributes to widespread trading of prescribed medication among prisoners, risking future deaths.
Addressed to: HM Prison Usk; Ministry of Justice
AI-generated concerns summaryConcerns were raised about the lack of a national system to flag high-risk pregnancies and poor communication regarding induction plans. There was also a lack of clear guidance for student midwives on escalation processes and for staff on when to use admission CTG monitoring.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a culture among some teenagers viewing knife possession as impressive and not understanding the risks, alongside the ease with which knives could be purchased. Education and schools are identified as having a vital role in shaping attitudes towards knife carrying.
Addressed to: Department for Education
AI-generated concerns summaryInadequate training of doctors on eating disorders and MARSIPAN guidance, a lack of clear pathways for accessing specialist advice, and referral criteria for eating disorder services that exclude patients with very low BMIs, meaning non-specialists coordinate their care.
Addressed to: Academy of Medical Royal Colleges; Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust; Health Education England; NHS Bury Clinical Commissioning Group; NHS England; NHS Greater Manchester Integrated Care Board; Northern Care Alliance NHS Foundation Trust; Priory Group; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner identified gaps in the patient pathway for ERCP procedures, including insufficient identification of patient factors, lack of robust systems for recording procedure vetting, and non-personalised consent processes, compounded by a lack of professional accountability.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of availability of sustained daily supported eating for patients with anorexia nervosa. This treatment, recommended by clinicians, could be more effective and less costly than repeated inpatient admissions.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the GP practice lacks a written procedure or guidance for administrative staff on triaging incoming correspondence, potentially leading to medical staff not seeing communications requiring action.
Addressed to: Croft Shifa Health Centre
AI-generated concerns summaryThe coroner notes that Network Rail has not responded to the British Transport Police's recommendation to curtail access to railway tracks at a specific location, indicating the identified weakness remains unaddressed.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner raised concerns about the adequacy of crash and sensor mat provision, documentation of their use, and accident reporting. Further issues included note-taking, staff training for visual checks at handover, and protocols for wound management and admission documentation.
Addressed to: Aden Nursing Home
AI-generated concerns summaryThe coroner identified that risks of recurrent impulsive self-harm in specific situations were not fully assessed for the period after sentencing. There was uncertainty whether this was due to policy requiring imminent risk or its misinterpretation.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner raises concerns about the lack of a structured approach for recording and responding to family concerns regarding a prisoner's welfare, and the need to review security fences preventing the transfer of prohibited items between prison units.
Addressed to: HMP Guy’s Marsh and Prisons and Probation Service
AI-generated concerns summaryThe coroner identified non-standardised meconium terminology and incomplete medical records. Concerns also included the absence of a local policy for centralised CTG monitoring and the trust's deviation from national guidance on hourly 'fresh eyes' reviews in labour.
Addressed to: Homerton University Hospital NHS Trust
AI-generated concerns summaryThe coroner identified a lack of clear processes for documenting, requesting, and chasing emergency ambulances, which led to communication errors. This resulted in a patient not being kept nil by mouth, and raises questions about the protocol for joint registrar consultations for specific conditions.
Addressed to: Cwm Taf Morgannwg University Health Board