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 noted that the patient's care plan prioritized self-management over safety in absconding situations, which appeared incompatible with Mental Health Act detention duties. Concerns were also raised about informal decision-making for ground leave and unclear definitions of physical interventions for staff.
Addressed to: Leeds and York Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient note-keeping, a lack of detailed future care planning to manage a high-risk patient, and the absence of support for the carer during acute deterioration. Additionally, the carer was not actively involved in the discharge process.
Addressed to: Cornwall Partnership (Foundation) Trust
AI-generated concerns summaryThe coroner noted issues with CTG monitoring equipment requiring staff to switch screens and manually record data, obscuring the graphic trace. Concerns were also raised that the Trust's systems did not ensure obstetric staff had completed mandated annual CTG training.
Addressed to: Department of Health and Social Care; Queen’s Hospital
AI-generated concerns summaryThe London Borough of Redbridge adult social care team was unable to properly investigate most safeguarding referrals, appoint social workers in a timely manner, or carry out home suitability assessments for vulnerable residents during January-March 2021.
Addressed to: Department of Health and Social Care; London Borough of Redbridge
AI-generated concerns summaryVenous thromboembolism reviews were not undertaken at 24 and 72 hours post-admission, and prescribed daily heparin injections were omitted. An omission of medication was noticed but not reported through the Trust's incident reporting system.
Addressed to: Department of Health and Social Care; Queen’s Hospital
AI-generated concerns summaryThe coroner noted inadequate pressure damage prevention due to infrequent reviews, and frontline staff lacking a broad view of medical needs as 'Restore 2' training was not cascaded. Senior staff's culture of obfuscation hindered learning from adverse events.
Addressed to: My Care Ltd; My The Orchards Ltd; Nottinghamshire County Council; Sherwood Forest Hospitals NHS Foundation Trust; The Care Quality Commission
AI-generated concerns summaryThe Crisis Resolution Home Treatment Team prioritised preventing hospital admissions over life protection. Staff relied on a patient’s stated suicidal intent despite a fluctuating history, and the Trust's investigation was inaccurate, missing key concerns.
Addressed to: Aviva Insurance; Nottinghamshire Healthcare NHS Foundation Trust; Nottinghamshire Police
AI-generated concerns summaryThe coroner noted the absence of a centrally funded national tram safety passenger group.
Addressed to: Bombardier Transportation UK Ltd; Light Rail Safety and Standards Board; Transport Focus; Bombardier Transportation UK Ltd; Transport for London; Light Rail Safety and Standards Board; UKTram; UKTram; The Department for Transport; Transport Focus; Transport for London; UKTram
AI-generated concerns summaryThe coroner noted the Care Quality Commission does not routinely check window restrictors during inspections. Concerns were also raised about St John's Nursing Home, where residents without capacity could leave unaccompanied due to unstaffed reception areas on weekends.
Addressed to: Care Quality Commission; St John’s Nursing Home
AI-generated concerns summaryThe coroner noted a lack of guidance for GP surgeries on mitigating risks associated with non-clinicians assessing appointment urgency, and for London Ambulance Service crews on family communication when referring to police. Concerns were also raised that police forces may lack practical guidance for safely conveying patients when ambulances are …
Addressed to: College of Policing; London Ambulance Service; NHS England
AI-generated concerns summaryThe coroner noted that despite a referral to Adult Social Care due to significant safety concerns, no safeguarding action was taken, particularly after the individual did not respond to telephone contact and no in-person visit was made.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner noted the agency nurse's sub-optimal care and raised concerns that the agency had not provided additional training or requested a reflective statement for the nurse following the incident.
Addressed to: MedPure Healthcare
AI-generated concerns summaryThe coroner notes that the ACCT process permits early closure of plans for newly transferred prisoners, which limits the time available for staff to assess and understand the individual's needs and for inter-agency communication. There is an identified need for a mandatory review period to ensure proper assessment before closure.
Addressed to: Department of Health and Social Care; HMP Belmarsh; Ministry of Justice; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a propping device and warning signs on an agricultural trailer that should have complied with safety regulations. Concerns were raised that many similar trailers are in use without these safety features, posing a risk of future accidents.
Addressed to: Bailey Trailers Ltd
AI-generated concerns summaryThe coroner identified that the local S136 Multi-Agency Policy requires streamlining and reformatting to be fit for purpose. There is also insufficient training for police and ambulance crews on recognising medical emergencies and the effects of restraint, alongside inadequate monitoring of detainees subject to restraint.
Addressed to: Association of Ambulance Chief Executives; Bedfordshire Police; EEAST; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner identified inadequate diabetes care planning and monitoring before discharge, alongside insufficient communication between inpatient, community mental health teams, and GPs. There was also a lack of formal mental capacity assessments and robust audit systems.
Addressed to: Greater Manchester Mental Health NHS Trust
AI-generated concerns summaryPhysical Education Instructors were unaware of PSI 58/2011 requirements, and communication gaps meant officers responsible for welfare checks were not informed Caden felt unwell. The wing officer did not ensure Caden saw healthcare nor hand over this information to their successor.
Addressed to: HMYOI Cookham Wood
AI-generated concerns summaryThe coroner identified issues with 111 service call handlers not correctly following algorithms or recognising complex cases involving disabilities, alongside a lack of robust systems for disabled callers. Concerns also included inadequate clinical advisor expertise and the public being potentially misled about the 111 service's role.
Addressed to: Health Education England; NHS Digital; NHS England; SECAMB
AI-generated concerns summaryThe coroner noted the absence of a system for tracking missed outpatient appointments in non-cancer NHS cases, which could prevent unnecessary deaths and save administrative time if introduced.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified concerns regarding Patient Transport UK Ltd's practice of placing detained mental health patients on the floor of secure vans without restraints, especially for medically vulnerable individuals. There was also a lack of incident review and staff reconsideration of vehicle suitability.
Addressed to: Patient Transport UK Ltd