Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryInadequate risk review and care planning were identified before discharge and during Home Based Treatment Team care, particularly for managing suicidal thoughts. The coroner also noted HBTT staff did not sufficiently assess risk changes, and found deficiencies in the trust's audit system and SUI investigation.
Addressed to: Greater Manchester Mental Health NHS Trust
AI-generated concerns summaryThe coroner noted that signs prohibiting swimming near a waterfall were obscured by vegetation and appeared aged, recommending a review to make the dangers more explicit and noticeable.
Addressed to: Harden & Bingley Park Ltd
AI-generated concerns summaryThe coroner noted the Philips Respironics AF 541 mask's 'push on' connection to the BIPAP ventilator tubing is prone to coming undone, especially with a filter. A more robust docking mechanism is suggested.
Addressed to: Department of Health and Social Care; Mid Yorkshire Hospitals NHS Trust; Philips Respironics
AI-generated concerns summaryThe coroner noted staff's insufficient understanding and acceptance of confirmation bias and raised concerns about the digestion of relevant newsletters. The slow rollout of confirmation bias training means many staff remain untrained, creating an ongoing risk.
Addressed to: Doncaster and Bassetlaw NHS Foundation Trust; Healthcare Safety Investigation Branch; Switalskis Solicitors
AI-generated concerns summaryPolice officers did not recommend hospital attendance for an individual appearing inebriated but with a serious underlying injury. The coroner identified a need for enhanced police training and national policy on ensuring medical assessment for such individuals.
Addressed to: Avon and Somerset Police; College for Policing; Home Office; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner highlighted the need to review the Police Missing Person Policy to ensure its effectiveness and suitability for purpose.
Addressed to: Essex Police; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted the absence of a daily supervising officer in SACU, which led to ad-hoc task allocation and incomplete hourly checks, including a missed check on Mr Todd's cell. There was no real-time system to ensure compliance with these checks due to paper-based records and varying staffing levels.
Addressed to: HMP Durham
AI-generated concerns summaryThe coroner noted that existing suicide prevention measures at a known location were not effective, as the deceased was able to jump within 2 minutes 30 seconds of entering the area.
Addressed to: Calderdale Council
AI-generated concerns summaryThe coroner noted an increased incidence of severe nutritional anaemia in paediatric settings in the Yorkshire & Humber region in 2020. This was linked to reduced health consultations, limited social contact, and widening socio-economic inequalities during the pandemic.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a risk arising from dog attacks not being fully investigated and, where appropriate, dogs not being euthanised, which could lead to further serious incidents.
Addressed to: Devon and Cornwall Police Constabulary; Dog Legislation Office
AI-generated concerns summaryThe coroner identified concerns regarding the supervision of a patient experiencing poor mental health, who was left alone in a hospital waiting area and subsequently left before being assessed.
Addressed to: Cheshire Wirral Partnership; North West Ambulance Service; Wirral University Teaching Hospital
AI-generated concerns summaryThe coroner raises concerns about the lack of mandatory requirements and standards for water depth gauges at river fords, the absence of mandatory inspection and maintenance for these features, and the need for mandatory inter-agency information sharing regarding incidents.
Addressed to: Department for Transport
AI-generated concerns summaryEmergency Department staff do not routinely access or review electronic Patient Report Forms due to difficulties with the system, relying instead on verbal handovers. This practice risks critical patient information being missed, which could lead to future deaths.
Addressed to: East Midlands Ambulance Service NHS Trust; Nottingham University Hospitals NHS Trust; Sherwood Forest Hospitals NHS Foundation Trust; Clinical Commissioning Group for Nottingham City and Nottinghamshire; NHS England
AI-generated concerns summaryThe coroner noted numerous failings in Mr. Blackburn's ACCT process, including delays in initial reviews, incomplete documentation, insufficient multi-disciplinary involvement, and required observations not being carried out. There were also concerns that prison staff did not fully understand their ACCT obligations.
Addressed to: HMP Hewell; Practice Plus Group
AI-generated concerns summaryInconsistent and undetailed record-keeping hindered a holistic view of the patient and led to assumptions about food refusal, delaying the recognition of deterioration. Oral handover of GP advice was not recorded, and no action plan was created for monitoring fluid and food intake.
Addressed to: Care Quality Commission; Sunnyside Nursing Home
AI-generated concerns summaryConcerns were raised that numerous doctors incorrectly interpreted scans, mistaking a fluid-filled cyst for a full bladder. This led to unnecessary re-catheterisations of the patient.
Addressed to: Royal Stoke University Hospital
AI-generated concerns summaryThe coroner noted that Mrs Lashley's mobility care plan was not updated to reflect the need for more frequent observation, and progress notes by staff did not accurately record the frequency of checks performed.
Addressed to: Cherry Orchard Nursing Home
AI-generated concerns summaryThe coroner noted inadequate assessment of mental capacity by local authority staff, which compromised discharge planning. Multi-agency working also suffered from assumptions about responsibility, leading to an incomplete needs assessment.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that reception staff did not adequately assess a distressed patient's need for an urgent mental health appointment, raising concerns about a lack of awareness regarding when a patient requires a clinical assessment for mental health concerns.
Addressed to: Taff’s Well Medical Centre
AI-generated concerns summaryNo advice was given to a driver or their family regarding the impact of UTI-induced confusion on driving fitness. There were also insufficient road safety testing for older drivers and a lack of specific guidelines for sudden onset confusion or delirium affecting drivers.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency; General Medical Council