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 summaryAn inadequate regime of supplemented nasogastric tube feeding resulted in inconsistent calorie intake for the patient, who was challenging and not always able to consume sufficient calories orally.
Addressed to: Swansea Bay University Health Board
AI-generated concerns summaryThe Roman Catholic Diocese of Westminster's safeguarding team did not sufficiently scrutinise or follow up on allegations, leading to delays in the investigation and in providing information to the subject. There were also missed opportunities for pastoral support.
Addressed to: Catholic Standards Safeguarding Agency
AI-generated concerns summaryThe coroner noted delays in approving the standard operating procedure for communicating life-threatening blood results and a lack of evidence that a toxicology screen was performed. The report also highlights that ongoing delays in incident investigation and action implementation create patient safety risks.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryNeurological observations advised after a head injury were not continued as planned, and there was no clear reason or documentation in the medical records for their discontinuation.
Addressed to: Kent and Medway Social Care Partnership Trust
AI-generated concerns summaryConcerns were raised regarding the significant delay in obtaining lumbar puncture results, which contributed to a liver biopsy being performed and a delay in commencing antiviral treatment. Additionally, a trust policy for post-liver biopsy observations was not followed due to miscommunication, and these observations were not recorded.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding inadequate staffing levels in the Royal Gwent Hospital Emergency Department, which led to staff not following hospital protocol and NICE guidance on the frequency of patient observations. This issue is described as a frequent and ongoing problem.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe DVT/VTE risk assessment process considers only mobility unless 'Step 1' is passed, potentially overlooking other significant risk factors. Additionally, the risk assessment form lacks guidance for completion and definitions for key terms.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of protocol for Mental Health Act assessments for children unwilling to attend A&E. Concerns also included Ellis's insufficient safety plan, a deviation without updated risk assessment, and incomplete information sharing regarding his absconding history.
Addressed to: North East London NHS Foundation Trust
AI-generated concerns summaryConcerns relate to an unexplained downgrade of a patient's falls risk assessment during hospital transfer and subsequent observation levels not matching the assessed risk. There was also insufficient written evidence of daily reassessments and inconsistent use of falls assessment tools across hospitals.
Addressed to: Northumbria Health Care Trust
AI-generated concerns summaryThe coroner notes concerns regarding the downgrading of a patient's risk level from high to medium immediately following a suicide attempt. This decision was made by staff unfamiliar with the patient, contrary to the assessment of her long-standing care coordinator.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe GP surgery continued a medication prescription beyond recommended guidelines without review. Concerns also included the lack of re-referral to mental health services despite instructions, and access to excess medication contrary to overdose mitigation measures.
Addressed to: Newbury Group Practice; Newbury Park Health Centre
AI-generated concerns summaryThe coroner noted concerns about the non-standardised colour coding, numerous types, and variable optimal positions of breathing system filters and HMEs, leading to widespread confusion and a lack of knowledge among ICU staff. This situation requires review, simplification, and standardisation.
Addressed to: Faculty of Intensive Care Medicine; Royal College of Anaesthetists
AI-generated concerns summaryThe coroner identified inadequate communication between paramedics on scene and the HEMS dispatch desk regarding a patient's critical clinical condition, noting that relevant information was neither fully offered nor requested.
Addressed to: London Ambulance Service NHS Trust; London’s Air Ambulance
AI-generated concerns summaryA police officer was unaware of the Lincolnshire Police Concern for Welfare Policy Document PD238 and did not follow required procedures for mental welfare reports. The coroner also questioned officer training and awareness regarding this policy.
Addressed to: Lincolnshire Police
AI-generated concerns summaryCare plans for the resident did not record incidents of aggression towards staff, nor was a safeguarding alert raised for such an incident. Additionally, staff appeared unaware of the contents of the resident's care plan.
Addressed to: Clifton Court Nursing Home
AI-generated concerns summaryThe coroner noted that concerns about an individual professional's capabilities should be referred to the relevant professional body by the employer promptly, as delays risk other patients.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of formal plans for cattle movement, including contingency strategies and specific planning for young calves. Concerns were also raised about insecure holding areas, insufficient public warning during movement, and a gate issue at a bridleway entrance.
Addressed to: JM Nixon Ltd, Swinhoe Farm Belford Northumberland
AI-generated concerns summaryThe coroner noted a gap in enforcement powers to address fire risks in residential properties, particularly those arising from hoarding behaviour.
Addressed to: Fire and Communities, Ministry of Housing; Home Office
Addressed to: Head of Healthcare) and; HMP Pentonville
AI-generated concerns summaryConcerns were raised regarding the surgery's incorrect categorisation of a RAST test, the prescription of a single EpiPen contrary to NICE guidance, and the lack of a referral to an allergy clinic or follow-up.
Addressed to: Hainault Surgery; SMA Medical Practice