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 not all clinical staff in prisons can access the NOMIS system, which holds critical prisoner information, because training for it is not compulsory for them. This lack of access to information puts prisoners at risk.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of awareness among electricians regarding the risk of lethal gas accumulation in transformers and the need for adequate oil. Manufacturer's manuals and maintenance recommendations did not address these hazards, posing a potential risk for comparable transformers.
Addressed to: Hirst Electrical Plant Hire Services UK Ltd
AI-generated concerns summaryThe coroner raised concerns that occupied houses boarded up after forced entry may lack alternative safe exit routes for residents, as was the case for Mr Martin.
Addressed to: Jigsaw Homes Tameside
AI-generated concerns summaryThe coroner identified a lack of a clear system for communicating to families and friends which items are designated as 'restricted' for a mental health ward patient. This impacts their awareness and ability to assist in ensuring the patient's safety.
Addressed to: Department of Health and Social Care; Hellesdon Hospital
AI-generated concerns summaryThe coroner noted that elderly individuals can purchase mobility scooters online or from various stores without any assessment of their suitability or competence to use them. This contrasts with assessments conducted for Motability scheme clients or specific private sales.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryIncompatible IT systems across NHS health providers prevent access to patient notes and records. This leads to specialist mental health units often not receiving complete patient history information upon referral.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the absence of authoritative guidance for assessing dehydration in individuals over 70 suspected of having gastroenteritis, which could include symptoms, signs, and advice on face-to-face assessment.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryConcerns relate to the bridge's accessible parapet, its known discussion as a suicide location, and the lack of monitored CCTV or lighting to detect at-risk individuals. Pedestrians at the base are also at risk from falling persons.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted concerns about delays in COVID-19 swab results for inpatients, which led to asymptomatic infectious patients remaining on non-Covid wards and potentially spreading infection. It was unclear if this issue had been resolved by other trusts, meaning the risk might remain.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified insufficient confirmatory checks for endotracheal tube placement and a diagnostic fixation that inhibited other staff. Concerns included an inhibitory hierarchical structure, team malfunction during the emergency, and variable ventilator display configurations.
Addressed to: Milton Keynes University Hospital, Chief Medical Officer and Royal College of Anaesthetists
AI-generated concerns summaryA DVT was not diagnosed due to lack of physical examination during a telephone GP consultation, and a high D-Dimer result did not trigger an electronic system alert. Also, existing NICE guidance lacked Covid-19 specific risk information for clots.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted that telephone consultations during the pandemic limited comprehensive mental health assessment. Additionally, the GP practice did not refer the patient to the crisis team, and there was unclear guidance for GPs on when to make such referrals.
Addressed to: NHS England; Stockport Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns about the lack of an admission process at Haywood Hospital's Grange Ward to assess the needs of patients, particularly those at high risk of falls, and to implement appropriate preventative measures.
Addressed to: Haywood Hospital; NHS England
AI-generated concerns summaryThe coroner noted a lack of skin integrity assessments and preventative measures while Mr Humphries was in A&E for a prolonged period. Advice was not sought from external professionals or the nursing home when he resisted being turned.
Addressed to: Croydon Health Services NHS Trust
AI-generated concerns summaryThe coroner noted a lack of call bell response time monitoring, inadequate staffing levels leading to patients not receiving timely assistance, and the absence of falls risk assessments for a patient at risk across multiple hospital wards.
Addressed to: Princess Royal University Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the lack of preventative signage at a road traffic collision site, specifically mentioning hidden dip warnings and notifications of recent incidents to improve awareness.
Addressed to: National Highways; Suffolk Highways
AI-generated concerns summaryThe coroner raises concerns about Philips central cardiac monitoring stations (model M3151) where alarms self-terminate when certain abnormal heart rhythms correct themselves, risking future deaths if not addressed by the manufacturer.
Addressed to: Philips Electronics UK Ltd
AI-generated concerns summaryThere was insufficient information sharing and coordination between the NHS Mental Health Trust, GP, and private therapist, leading to an incomplete understanding of risks and treatment. Remote mental health assessments and unaccompanied A&E attendance due to COVID-19 also limited comprehensive care.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner identifies a lack of national guidance for DVT diagnosis when bilateral leg swelling is present. Concerns are also raised about unclear VTE risk assessment forms and discharge letters, which can lead to inconsistent prophylactic anticoagulation.
Addressed to: NHS Quality, Safety and Investigations
AI-generated concerns summaryThe coroner noted concerns regarding the continued prescription of powerful painkillers, including liquid morphine, to a patient known to consume significant alcohol and not adhere to medication dosage instructions.
Addressed to: Stockport Clinical Commissioning Group