Browse 6,471 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 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
AI-generated concerns summaryThe coroner identified insufficient ACCT training for staff at HMP Birmingham, leading to an ACCT document not being opened. Concerns were also raised about an unsatisfactory handover of psychiatric assessment information between HMP Birmingham and HMP Hewell, with no corrective action taken.
Addressed to: HMP Birmingham
AI-generated concerns summaryOFSTED's inspection following a child's death lacked documented requirements, pre-planning, consideration of relevant safeguarding evidence, and critical appraisal. There was also no guidance on "exceptional circumstances" for report publication.
Addressed to: OFSTED
AI-generated concerns summaryThe coroner noted that a S.136 Mental Health Act assessment was conducted without full information from CNWL or discussion with relevant police officers, recommending an urgent review of S.136 procedures in Milton Keynes.
Addressed to: CNWL and Chief Constable
AI-generated concerns summaryInsufficient and unworkable IT facilities at the hospital prevented timely electronic record-keeping, leading to crucial clinical information being unrecorded or omitted in patient notes. This reliance on memory or temporary paper notes poses a risk to patient safety.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryConcerns were raised about the lack of formal mental capacity assessments for treatment refusal and insufficient specialist input for severe exfoliative dermatitis and malnutrition. Additionally, the Department of Work & Pensions required an in-person benefits claim from a severely ill inpatient.
Addressed to: Department for Work and Pensions; Kent & Medway Social Care Partnership Trust; Maidstone & Tunbridge Wells NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that MBRRACE UK 2019 guidance for Point-of-Care Ultrasound Scans was not followed, potentially leading to inappropriate medication. Additionally, obstetricians lacked specific training in identifying intra-abdominal bleeding, and this guidance was absent from national resuscitation protocols.
Addressed to: Resuscitation Council UK and Royal College of Obstetrics & Gynaecology
AI-generated concerns summaryThe coroner identified a need for improved training of prison staff in responding to medical emergencies and using the ERIC system. Concerns were also raised regarding liaison between healthcare and ambulance services, and communication between healthcare personnel at emergency scenes and control rooms.
Addressed to: HMP Lancaster Farms
AI-generated concerns summaryThe coroner identified insufficient monitoring of care plan compliance, a lack of robust incident reviews, and support workers not being included in client progress meetings. Concerns were also raised regarding a lack of clarity on procedures for serious self-harm incidents and the absence of a formal escalation process with the …
Addressed to: Care Quality Commission; Heathcotes Group
AI-generated concerns summaryStaff were unaware of the Trust's Standard Operating Procedure for Enhanced Care/Observation, and relevant staff had not received training for the SafeCare system. There was also no procedure to record and audit the efficacy of training delivery.
Addressed to: City Hospitals Sunderland NHS Foundation Trust; The Jackloc Company Limited; Department for Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the positioning, size, and brightness of rear-mounted flashing LED lights on agricultural trailers, noting they can mask the indicator lights and make turn signals difficult to discern.
Addressed to: Department for Transport
AI-generated concerns summaryA final decision is pending on whether to incorporate an artificial stall warning capability in the Hawk Mk 1 aircraft, which may stall without pre-stall buffet. The current simulator training also does not accurately reflect the aerodynamic model of an RAF aerobatic aircraft with a smoke pod fitted.
Addressed to: Ministry of Defence
AI-generated concerns summaryConcerns included the patient being transferred between hospitals without escort or handover, and a 10-hour A&E stay lacking clear instructions for urgent treatment. No falls risk assessment was performed despite observed confusion, leading to a subsequent fall.
Addressed to: Leeds Teaching Hospitals NHS Foundation Trust; One Medical Group; Department of Health
AI-generated concerns summaryHealthcare professionals used inconsistent and subjective criteria for risk assessment, leading to variable and poorly understood risk grades. The coroner also noted a lack of adherence to online training materials and no plan to address these issues.
Addressed to: Greater Manchester Police; Mitie
AI-generated concerns summaryThe teaching assistant was not trained in cardiopulmonary resuscitation (CPR), and no staff member attempted CPR when Khadija became unresponsive. The coroner noted the school would benefit from frequent CPR training for staff.
Addressed to: Swiss Cottage Special School
AI-generated concerns summaryThe coroner noted that Working with Risk documentation was not completed during the initial nine contacts with Mr Hammond, which resulted in an unsatisfactory care plan.
Addressed to: Coventry and Warwickshire Partnership Trust
AI-generated concerns summaryThe coroner raised concerns that Department of Education e-security guidelines for schools are outdated and insufficiently robust, lacking regulatory oversight on web filtering software and appropriate blocklists. There is also no consideration in the guidance for advanced monitoring systems to detect age-inappropriate content.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted that the lack of independence in DCMH care risks under-reporting of mental health symptoms, and the primacy of DCMH views in risk assessment meetings may lead to inadequate risk management plans. There is also no single composite risk assessment and care plan.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner raises concerns about Children's Social Care closing cases for young people during mental health inpatient admissions, leading to a lack of social worker input into discharge planning, which may impede therapeutic relationships and increase risks post-discharge.
Addressed to: Department of Health & Social Care
AI-generated concerns summaryPrison officers are not required to obtain a response from all prisoners during welfare checks, including those appearing asleep, which is contrary to PSI 75/2011. This lack of engagement means distressed prisoners may not be identified during checks.
Addressed to: HMP Wakefield and Minister of State for Prisons and Probation