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 that the Trust's risk assessment and management policy was not fully embedded in practice by nursing staff. Concerns were also raised about the integrity of electronic medical records due to delayed validation and undisclosed post-death amendments.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in the provision of a multidisciplinary team and a proactive prevention model in dementia care. Concerns included the lack of comprehensive individual assessments, continuous family engagement, person-centred approaches, and the practical implementation of policies.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the industry practice of 'mounding' loads above the sides of tipper lorries, which makes standard sheeting systems ineffective and increases the risk of material falling from vehicles. This practice leaves parts of the load uncovered and susceptible to being blown off.
Addressed to: Driver and Vehicle Licensing Agency; Paul Wainwright Construction Services Ltd
AI-generated concerns summaryConcerns included a lack of clarity in the supported housing association's duty of care and staff interpretation, with agreed hourly checks and welfare checks not performed. Additionally, risk assessments were not updated, and problems were not escalated to management.
Addressed to: Adullam Homes Housing Association
AI-generated concerns summaryThe coroner noted that the deceased had not received an annual medication review, and that such reviews do not routinely include enquiries about over-the-counter medications taken alongside prescribed ones.
Addressed to: Department of Health and Social Care; Manchester Health and Social Care Partnership; Uplands Medical Practice
AI-generated concerns summaryThe coroner raised concerns about the absence of clear and visible signage at the railway station warning of the live electrified rail, particularly at the station entrance and central platform area.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted concerns about the uneven condition of a narrow pedestrian pavement near Alma Street, Brynmawr, which could pose a risk to people, particularly the elderly with reduced mobility.
Addressed to: Blaenau Gwent County Borough Council
AI-generated concerns summaryThe coroner identified issues with insufficient supervision of junior doctors and poor medical record keeping within the emergency department. These factors contributed to diagnostic overshadowing, a failure to diagnose an acute condition, and inadequate escalation of complex cases, alongside concerns about patient transfer procedures and safety-netting advice.
Addressed to: Queen’s Hospital
AI-generated concerns summaryThe coroner identified an absence of national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn/DCT positive infants, especially regarding care after acute treatment and following discharge.
Addressed to: National Institute for Clinical Excellence and British Association of Perinatal Medicine
AI-generated concerns summaryFamily information regarding self-harm risk was not fully incorporated into care plans and risk assessments, and care coordinators lacked designated time for contemporaneous note-taking. The coroner also highlighted the absence of long-term plans to address the mental health needs of primary carers.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner requested confirmation of the full implementation of a December 2019 action plan, including implementation dates for all nine points. They also sought reasons for any partial implementation of the plan.
Addressed to: United Lincolnshire Hospital Trust
AI-generated concerns summaryThe coroner noted that Medica, who reports CT scans for LHCH, has not confirmed the use of 3D reconstruction for aortic stent surveillance, raising concerns that other patients may have unidentified leaks and face delayed treatment.
Addressed to: Medica Reporting Ltd and Liverpool Heart and Chest Hospital
AI-generated concerns summaryThe coroner noted a lack of awareness among senior clinicians regarding Panton Valentine Leukocidin (PVL) Staphyloccus Aureus and relevant hospital protocols. Concerns were also raised about problematic communication between critical care and microbiology teams and a lack of awareness of internal hospital systems.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding Pontins' security staff training, noting that staff were responsible for seeking their own training and ground restraint methods were in policy but not taught in accredited courses. There were also concerns about a lack of monitoring for positional asphyxia during prone restraint and unclear staff …
Addressed to: Brittania Jinky Jersey Limited; Brittania Hotels Group Limited
AI-generated concerns summaryThe coroner identified a national shortage of specialist inpatient beds for individuals with eating disorders, leading to delays in accessing urgent medical treatment.
Addressed to: NHS England
AI-generated concerns summaryMr. Lott was not transferred to critical care despite high NEWS 2 scores and unmanaged hypoglycemia. The report also notes insufficient escalation to on-call staff when the consultant was unavailable, and identifies a need for clear transfer policies for nursing staff.
Addressed to: Nuffield Hospital
AI-generated concerns summaryThe coroner noted that individuals can easily manipulate the current prescription system due to a lack of a central record for issued prescriptions. This allows people to obtain excess medication from multiple NHS and private providers acting in isolation.
Addressed to: NHS England
AI-generated concerns summaryA lack of follow-up for Eva's neutropenia occurred due to erroneous care assumptions between hospitals, missing a diagnosis opportunity. There was also insufficient communication to her parents about the condition and the need for urgent care for infections.
Addressed to: Southport and Ormskirk Hospital NHS Trust, Southport and Formby District General Hospital
AI-generated concerns summaryThe coroner noted that a doctor's request to district nurses specified catheter care but not catheter change, indicating that the language used by doctors in this situation could be clearer.
Addressed to: Lower Clapton Group Practice
AI-generated concerns summaryThe coroner identified a knowledge gap among doctors regarding Capnocytophaga canimorsus infections from dog/cat bites and the increased risk for susceptible individuals. There is also a need for greater public awareness about seeking urgent medical attention after such bites when underlying illnesses are present.
Addressed to: Public Health England