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 identified a lack of a system to ensure that patients under the care of the CMHT were allocated an active Care Co-Ordinator. The allocation often appeared to be a "box ticking" exercise, with assigned individuals not fulfilling the required tasks such as seeing the patient or completing a …
Addressed to: NHS England; North Staffordshire Combined Healthcare Trust
AI-generated concerns summaryThe coroner identified gaps in inter-agency information sharing and recording of protective orders by various services. Additional concerns included deficiencies in the Child Maintenance Service's handling of domestic violence reports, particularly limited staff training and a restrictive policy for escalating reported threats.
Addressed to: Department for Work and Pensions; HM Courts and Tribunals Service; Home Office; Metropolitan Police Service; Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns about the absence of falls risk assessments and trolley rail assessments for vulnerable and elderly patients in A&E, noting a lack of national guidelines for these procedures. No mental tests or therapy assessments were conducted for patients awaiting further tests.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted concerns that police did not adequately investigate multiple reports of harassment made by family members prior to the deceased's death, potentially dismissing such incidents.
Addressed to: Staffordshire Police
AI-generated concerns summaryThe coroner identified a lack of national guidance for mental health practitioners on the risks associated with certain substances, noting that Serious Incident Reviews may not adequately incorporate these risks. Further concerns were raised regarding the absence of national guidance for A&E clinicians on the appropriate use of specific antidotes, …
Addressed to: Department of Health and Social Care; Public Health England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted low compliance with the paediatric sepsis screening tool, a lack of consultant review prior to child discharge, and no alert system for ICE results for the paediatric team. Concerns were also raised about unrecorded discussions in Radiology meetings and potential login issues for locum doctors.
Addressed to: Care Quality Commission; Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted potential under-reporting of PEG allergy and a need for more research into its effects. Concerns were raised about the lack of clear information on medical product labelling regarding PEG's presence, dose, and molecular weight, compounded by inconsistent nomenclature.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted staff non-compliance with the Trust's therapeutic engagement and observation policy, specifically regarding night-time observations of patients believed to be sleeping. This issue has recurred over time despite previous incident reports.
Addressed to: Sussex Partnership Foundation NHS Trust
AI-generated concerns summaryThe coroner raised concerns that the failure to preserve key evidence meant the inquest could not be as full as it would otherwise have been, risking dangerous conditions going undiscovered.
Addressed to: HMP Exeter
AI-generated concerns summaryThe coroner noted that CPAP machines use the same alarm for minor leaks and total oxygen cessation, which complicated identifying the cause of a patient's low oxygen saturations when multiple alarms were sounding simultaneously.
Addressed to: Medicines and Healthcare products Regulatory Agency; NHS England; NHS Improvement
AI-generated concerns summaryConcerns were raised regarding inadequate clinical assessment and follow-up for a deteriorating patient, with no documented abdominal examination or early medical review. The report also notes inconsistent medical record-keeping and confusing online patient records.
Addressed to: Royal Free Hospital
AI-generated concerns summaryThe coroner noted inconsistent implementation of falls prevention measures, allowing a resident to move unsupervised. Concerns were also raised regarding staff feeling pressured, potentially due to staffing levels, and the optimal location of residents within the care home relative to their needs.
Addressed to: Gwern Alyn House Residential Home
AI-generated concerns summaryThe coroner noted a high number of road traffic collisions on the road, with drivers frequently exceeding the 50mph speed limit. Concerns were raised about the crossroads having give-way signs instead of stop signs, and reduced visibility at night or in bad weather.
Addressed to: Norfolk County Council
AI-generated concerns summaryThe coroner notes that Large Goods Vehicles have significant blind spots behind them, even with multiple mirrors, and drivers often reverse without assistance. There is no mandatory legal requirement for LGVs to be fitted with rear cameras, which could prevent future deaths and accidents.
Addressed to: Department for Transport
AI-generated concerns summaryConcerns included staff non-compliance with observation and dietary policies, incomplete record-keeping, and infrequent multi-disciplinary team meetings that did not address weight management. The coroner also noted issues with a software system and the absence of CCTV.
Addressed to: Jeesal Akman Care Corporation Ltd; Jeesal Holdings Ltd; Jeesal Residential Care Services; Norfolk and Norwich University Hospital
AI-generated concerns summaryThe coroner noted the absence of national guidance for managing large babies without maternal diabetes. Concerns were raised regarding insufficient information provided to mothers about the risk of death from shoulder dystocia, and its omission from the RCOG patient information leaflet.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified inadequate monitoring and observation following a patient's significant deterioration, and raised concerns about the appropriate level of care for severe pancreatitis patients. An action plan addressing these issues had not been fully implemented a year after the death.
Addressed to: University Hospital Lewisham
AI-generated concerns summaryThe coroner noted a risk of further deaths and serious injuries due to the failure to replace old style road barriers with modern replacements.
Addressed to: South Wales Trunk Road Agent; Welsh Government
AI-generated concerns summaryThe coroner noted concerns that the widely used CAM-ICU diagnostic tool may not consistently recognise all forms of delirium, particularly 'hypo symptoms' or paranoia. This could lead to sub-optimal diagnosis and treatment for patients across the country.
Addressed to: Liverpool Heart and Chest Hospital; National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner raised concerns about the absence of specific guidance for prison staff conducting welfare checks on vulnerable prisoners in HMP New Hall's First Night Centre, especially given a previous jury finding about the impact of lacking guidance.
Addressed to: Ministry of Justice