Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified insufficient guidance for care facilities on managing fire risk from residents and its escalation. Concerns also included the absence of a statutory requirement for sprinkler systems in such accommodation, alongside potentially delayed smoke detector activation.
Addressed to: Ministry of Communities, Housing and Local Government
AI-generated concerns summaryThe coroner noted inadequate documentation of skin inspections and observations over several days, indicating a systemic issue with staff not properly recording patient observations, which poses a risk to vulnerable residents.
Addressed to: Bromford Lane Nursing Home
AI-generated concerns summaryThe text outlines the circumstances of Lesley Powell's death, who was fatally struck by a motor vehicle while walking and crossing the A2100.
Addressed to: East Sussex County Council
AI-generated concerns summaryThe coroner noted a lack of knowledge among Probation officers regarding available mental health services, which resulted in Mr Salter resorting to criminal acts to obtain treatment. There was also poor engagement and collaboration with agencies and family.
Addressed to: National Probation Service
AI-generated concerns summaryThe coroner identified a "blind spot" in a door alarm system and raised concerns that other facilities housing vulnerable people may be using similar systems without being informed of the potential danger or manufacturer rectifications.
Addressed to: Instastop Ltd
AI-generated concerns summaryThe report highlights that a lack of face-to-face GP examination and patient support in hospital due to COVID may have contributed to a missed fracture. It also notes the absence of specific NICE guidance for managing femur fractures in the elderly.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryPandemic restrictions reduced support for Mrs. Rushworth at outpatient appointments and post-discharge, affecting history-taking and decision-making. Advice regarding her complex care and risks was not clearly conveyed to community professionals or family, leading to delayed recognition of her deteriorating health.
Addressed to: Greater Manchester Health and Social Care Partnership; NHS England
AI-generated concerns summaryThe coroner noted that Covid-19 restrictions impacted care delivery, with telephone consultations hindering the communication of deteriorating health to the GP. Delays in mental health services due to Covid-19 constraints and staffing issues also affected the provision of support.
Addressed to: Department of Health and Social Care; NHS England; Secretary of State of Health; Tameside Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified insufficient senior clinical input at Mayday Assistance Limited and a lack of clarity regarding overall medical management responsibility between Mayday Assistance Limited and air ambulance providers once an instruction has been given.
Addressed to: Mayday Group
AI-generated concerns summaryThe coroner identified a lack of specific guidance for overnight checks on vulnerable patients at risk of falls, even after a serious incident review. Concerns were also raised that the bedrails policy was not effectively circulated or understood by all relevant staff.
Addressed to: Pinderfields General Hospital
AI-generated concerns summaryThe coroner noted insufficient knowledge and training among care home staff regarding specialist equipment for pressure sore prevention and treatment, leading to incorrect use or non-use. A further concern was the point at which social care should transition to nursing care.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe report raises concerns about the lack of systems and appropriate pathways for individuals with severe mental health conditions who struggle to engage with services, leading to insufficient support and reliance on family care.
Addressed to: Essex Partnership University NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the security and proper management of prescribed medication within the care home, as methadone prescribed to a resident was found in a staff member's possession. The coroner inquired about audits and actions taken to address this.
Addressed to: Grassy Meadow Care Centre
AI-generated concerns summaryThe coroner noted an unacceptable delay in Mr Tokam's clinical assessment and the absence of a process to triage referral acuity or expedite urgent assessments.
Addressed to: Department of Health and Social Care; St Pancras Hospital
AI-generated concerns summaryThe coroner noted the absence of multi-agency discharge planning and a care and support plan for a patient with complex needs. Unclear internal processes for case allocation and information sharing were also highlighted.
Addressed to: Kent County Council
AI-generated concerns summaryInsufficient awareness among patients, families, and carers regarding the fire risks of flammable emollient creams, especially for immobile persons who smoke. There are gaps in ensuring referral to local Fire & Rescue Services for advice and assistance.
Addressed to: British Medical Association and Sussex Clinical Commissioning Groups
AI-generated concerns summaryThe coroner noted concerns regarding single-crewed bin lorries operating in darkness in areas vulnerable to vagrants. Key safety guidance on checking inside bins for people was missing from the primary supervision advice document.
Addressed to: WISH and Health and Safety Executive
AI-generated concerns summaryThere is an absence of national guidelines and designated referral pathways for children with achondroplasia, meaning general paediatric teams lack awareness of risks, and parents are not adequately informed about sudden death from foramen magnum stenosis.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryCommunication difficulties during the emergency call led to an ambulance being dispatched to the wrong address. The coroner also noted inadequate EOC follow-up and a lack of escalation or re-review of the original call to locate the patient.
Addressed to: South East Coast Ambulance Service
AI-generated concerns summaryThe coroner identified a lack of early dietician and mental health assessments, inaction despite documented weight loss, and an inability to adequately care for a mentally unwell patient refusing food. Concerns were also raised about excluding family from care and failing to recognise serious harm.
Addressed to: Hellesdon Hospital; Queen Elizabeth Hospital