Browse 6,458 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe trust's Sepsis Screening Tool was not deployed in the patient's assessment in the Paediatric Emergency Department. There was also ongoing work needed to ensure consistent application of this tool between different paediatric units.
Addressed to: National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThe coroner identified capacity issues affecting the timely admission and treatment of stroke patients in Cornwall, noting that only 35% were admitted to a stroke unit within 4.5 hours and only 55% spent over 90% of their time on a stroke unit.
Addressed to: Cornwall & Isles of Scilly Integrated Care Board; Royal Cornwall Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the absence of local or national data on police officers who died by or attempted suicide during misconduct investigations. There were also concerns about inconsistent implementation of the "STEP" campaign for officers exposed to trauma.
Addressed to: National Police Chiefs Council
AI-generated concerns summaryThe coroner is concerned that the national speed limit on the A684, combined with the design of M6 Junction 37, gives drivers insufficient time to react to vehicles crossing their path.
Addressed to: National Highways
AI-generated concerns summaryThe coroner noted issues with the ambulance service's unclear categorisation and escalation procedures for calls involving Acute Behavioural Disturbance with active restraint, which led to inappropriate Category 2 responses. There was also a discrepancy in training for Special Constables on recognising this condition.
Addressed to: Association of Ambulance Chief Executives; East of England Ambulance NHS Trust; Essex Police
AI-generated concerns summaryThe coroner noted insufficient evidence that the hospital had addressed the failings identified during the inquest.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner raised concerns about prolonged patient stays in the Emergency Department due to a lack of available hospital beds. This situation arises from delays in discharging medically fit patients, as community care providers do not consistently offer timely care packages or alternative placements.
Addressed to: Department of Health and Social Care; Kent and Medway Integrated Care Board; Kent County Council; Medway Council
AI-generated concerns summaryThe coroner noted multiple incidents, including a fatality, on a specific road stretch, highlighting the absence of pedestrian crossings, obscured driver visibility from parked vehicles, and insufficient street lighting and road markings.
Addressed to: Highways Department; Sandwell Local Authority
AI-generated concerns summaryThe coroner noted frequent overcrowding in the resuscitation department, stemming from delayed patient discharges due to insufficient timely community care packages and alternative placements from social and community healthcare providers.
Addressed to: Department of Health and Social Care; Kent and Medway Integrated Care board; Kent County Council; Medway Council
AI-generated concerns summaryThe coroner identified a lack of national and local written guidance for patient handovers between staff and wards, which led to incomplete or inaccurate information being passed, especially to agency workers. This posed a risk to patient care.
Addressed to: Dorset Healthcare University NHS Foundation Trust (DHUFT); National Institute for Health and Care Excellence (NICE); General Medical Council (GMC); Nursing and Midwifery Council (NMC)
AI-generated concerns summaryThe coroner highlighted a lack of routine ammonia testing and clear national guidelines for adults presenting with acute behavioural change and confusion. The Royal College of Emergency Medicine's guidance was not embedded in practice and lacked specificity for diagnosing rare metabolic disorders, including post-partum presentations.
Addressed to: Faculty of Intensive Care Medicine; Royal College of Emergency Medicine (‘RCEM’); The Royal College of Physicians; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner identified a lack of staff training and understanding regarding the reporting and escalation of serious clinical incidents. Concerns were also raised about the absence of effective processes for reviewing clinical notes to identify issues and for recording external incident referrals.
Addressed to: Torbay and South Devon NHS Trust
AI-generated concerns summaryThe coroner noted the deceased could access an unsecured item to form a ligature. Concerns were also raised about the difficult and dangerous access emergency services faced at the location, hindering their response.
Addressed to: Health and Safety Executive; Rossendale Borough Council
AI-generated concerns summaryA GP did not adequately scrutinise blood test results, specifically a markedly raised NT-Brain Natriuretic Peptide, which resulted in a delay for specialist assessment. The coroner highlighted the need for the GP surgery to review its processes and for NHS England to review guidance on laboratories flagging abnormal results.
Addressed to: NHS England; Quarry Bank Medical centre
AI-generated concerns summaryThe coroner identified gaps in firearms legislation, noting there is no requirement for licence holders to self-report illnesses, and no obligation for GP practices to record licence holding or report relevant issues to police.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe coroner noted a high rate of falling accidents in Waterfall Country due to inadequate signage concerning fall risks and walkers misunderstanding routes. Additionally, poor mobile signal in remote areas delays emergency services response times.
Addressed to: Bannau Brycheiniog National Park; Natural Resources Wales; Neath Port Talbot County Borough Council; Powys County Council; Rhondda Cynon Taf County Bouorgh Council
AI-generated concerns summaryThe coroner raised concerns that the police constabulary's use of 'suicidal ideation' was not understood by the public reporting missing persons, nor consistently by police staff, potentially affecting accurate risk assessment.
Addressed to: Devon & Cornwall Police
AI-generated concerns summaryThe coroner noted that a patient's previous gastric surgery and altered anatomy were not readily recognised, delaying investigation of complications after nasogastric tube insertion. There was a lack of national guidelines for nasogastric tube insertion in patients who had undergone prior gastric surgery.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns about insufficient staffing for patient observations and a lack of specific training for staff supporting neurodiverse patients. Problems with the implementation and oversight of the Oxevision monitoring system were also noted, alongside medication errors where prescribed changes were not correctly entered on charts.
Addressed to: Essex University Partnership Trust
AI-generated concerns summaryThe coroner noted concerns that high patient numbers create significant pressures on the hospital emergency department, leading to unwell patients remaining in ambulances. This delays access to critical interventions like blood tests and antibiotics, which can reduce survival chances for patients with suspected life-threatening infections.
Addressed to: Care Quality Commission; Department of Health and Social Care