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 concerns regarding a hospital issuing a 14-day prescription for medication already prescribed by the GP, which contradicted the GP's practice of issuing 7-day prescriptions to a patient with a high overdose risk and erratic compliance. This additional prescription may have contributed to medication stockpiling.
Addressed to: Sandwell and West Birmingham Hospital Trust
AI-generated concerns summaryThe coroner noted a lack of recorded safeguarding discussions during a welfare visit and a missed opportunity to consider safeguarding at an earlier stage, as the initial focus was on immediate health needs.
Addressed to: Devon County Council
AI-generated concerns summaryThe coroner noted insufficient dissemination of information about the Potentially Dangerous Persons (PDP) process within police forces and partner agencies. This led to a lack of understanding among staff, hindering the proper use of the process.
Addressed to: Hertfordshire Constabulary; Hertfordshire Partnership University NHS Foundation Trust; National Probation Service
AI-generated concerns summaryThe consultant psychiatrist relied on a patient's self-reported medication, leading to an incomplete risk assessment. There are also concerns about the inability of electronic systems to facilitate swift and accurate medication information transfer between primary and secondary care providers.
Addressed to: Basildon and Brentwood Clinical Commissioning Group; Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryConcerns were raised about a GP practice's administrative process for passing on information about suicidal thoughts, the lack of a meaningful mental health or risk assessment by the GP, and the robustness of the practice's internal review processes.
Addressed to: Linden Medical Group – Stapleford Care Centre; NHS Nottingham; Nottinghamshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted a lack of processes to ensure vulnerable individuals have working alarms, telephones, and heating upon returning home. Concerns were also raised about the sufficiency of social worker training and clear guidance for assessing premises suitability for discharge.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner noted the complexity of opioid tolerance and recommended the Department of Health produce a leaflet explaining tolerance and the serious risk of toxicity for patients prescribed opiate medication.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryHMP Leeds did not have any certified safer cells (anti-ligature cells) at the time of the death and still does not. Even cells with increased safety features do not meet the certified standard, enabling the individual to suspend himself in an ordinary cell.
Addressed to: Government Legal Department; HMP Leeds
AI-generated concerns summaryThe coroner raises concerns about the general lack of sepsis awareness in schools, noting the tragic consequences if the condition is left untreated. The report aims to promote greater sepsis awareness among school staff nationally.
Addressed to: Department for Education
AI-generated concerns summaryThe admissions assessment tool did not include a prompt for assessors to inquire about previous choking episodes, risking that relevant information would be missed during the assessment process.
Addressed to: Northern Care Alliance NHS Trust
AI-generated concerns summaryThe coroner notes that equipment for accurate tumour localisation during routine colonoscopies is not required. Furthermore, St Richards Hospital lacks a formal surgeon-to-endoscopist feedback system for tumour localisation or tattooing issues.
Addressed to: Association of Coloproctology of Great Britain and Ireland; British Society of Gastroenterology; Joint Advisory Group on GI Endoscopy; National Institute for Health and Care Excellence; Western Sussex Hospitals
AI-generated concerns summaryThe coroner identified a high number of fatalities on a section of track with multiple accessible pedestrian crossings, noting that Network Rail's efforts to reduce these risks have been hampered by local authority opposition.
Addressed to: Broxtowe Borough Council; Derbyshire County Council; Erewash Borough Council; Nottinghamshire County Council
AI-generated concerns summaryThe coroner notes that observing a person's chest and abdomen through a cell door hatch, a standard prison procedure, may be an unreliable method for checking if they are breathing, creating a risk of future deaths.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner identified that a sip test to exclude aspiration was not performed and a doctor did not act on an endoscopy report indicating a dangerous complication. There were also concerns about discrepancies in consenting procedures for endoscopy and inadequate record keeping by senior staff.
Addressed to: University Hospitals Plymouth NHS Trust
AI-generated concerns summaryThe coroner identified inaccuracies in the practice's computer coding for a patient's procedures and raised concerns about whether the system allowed overrides for accurate descriptions and if an auditing system existed for input accuracy.
Addressed to: Wilsden Medical Practice
AI-generated concerns summaryThe coroner noted sub-optimal training for Mental Health Act assessments, patient risk management, and assessors. There were also concerns about ensuring independent clinicians have reasonable access to patient data before MHA assessments.
Addressed to: East Sussex County Council; Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted residual staffing shortages in the dietetic team, resulting in delayed weekday assessments and an inability to provide weekend cover.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an inadequate supply of mobility aids for the Older People Assessment and Liaison (OPAL) team in the emergency department, noting only two zimmer frames for numerous patient areas. The responsibility and timeline for procuring additional aids were also unclear.
Addressed to: NHS England; University Hospitals Birmingham NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the Trust's contingency to manage multiple urgent face-to-face responses simultaneously. There was also a 12-hour delay between a call and a home visit, with no mechanism to identify unprogressed cases.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner noted residents were unaware of the 'Stay Put' fire policy in council-owned flats, and Stoke-on-Trent City Council had not changed its communication methods for this policy. This lack of resident awareness was identified as a risk of future deaths.
Addressed to: Stoke-on-Trent City Council