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 noted the absence of a clear method for documenting salivary bypass tubes in medical records, consent forms, and anaesthetic checklists. Concerns also included poor quality pre- and post-operative documentation and the hospital's process for requesting external treatment summaries.
Addressed to: Norfolk and Norwich University Hospital NHS Foundation Trust
AI-generated concerns summaryAn ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.
Addressed to: HMP Dartmoor
AI-generated concerns summaryThe organisation responsible for providing accommodation selected the deceased's care home, which later closed due to poor service, without first physically inspecting its suitability.
Addressed to: Care Quality Commission, Devon Partnership Trust and Plymouth Safeguarding Adult Partnership
AI-generated concerns summaryThe coroner noted poor communication of patient clinical observations and inadequate documentation during a telephone consultation between two hospitals. There was also a lack of clear guidance on when inter-hospital clinician dialogues should be documented.
Addressed to: Royal Stoke University Hospital and Birmingham Children’s Hospital
AI-generated concerns summaryThe coroner identified a lack of regulation, record of ownership, and licensing requirements for crossbows, unlike firearms and shotguns. Police currently have no record of who owns these weapons or how they are stored, despite their lethal capabilities.
Addressed to: Home Office
AI-generated concerns summaryThe prison control room delayed providing critical information, including the need for CPR, to the ambulance service, resulting in a lower emergency response category. The coroner notes concerns that staff may not recognise the importance of promptly updating the ambulance service with critical patient information.
Addressed to: HMP Long Lartin
AI-generated concerns summaryThe coroner identified issues with inoperable personal alarms due to a charging system failure. Concerns also relate to insufficient staff training and awareness of the charging policy, particularly for agency workers.
Addressed to: Options for Care Ltd
AI-generated concerns summaryThe coroner noted significant deficiencies in staff knowledge and application of Mental Capacity Act principles. Concerns included inadequate training, misunderstanding specific best interests decisions, and insufficient patient and family engagement in decision-making.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of clear protocols and communication regarding newly referred patients who do not engage with mental health services, specifically noting that GPs were not made aware of missed appointments. Concerns were raised about the existing policy for non-attendance, which lacked clarity on re-booking appointments and escalation …
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted prolonged hospital admission due to a shortage of MRI scanner availability and a national shortage of radiology staff, which resulted in the patient having a fall and contracting Covid-19.
Addressed to: Greater Manchester Health and Social Care Partnership; NHS England
AI-generated concerns summaryConcerns include a patient retaining prohibited items on a mental health ward despite searches, and staff making false observation entries. There was also insufficient post-tranquilisation monitoring, reflecting a wider organisational issue.
Addressed to: Dept. of Health and Social Care, Camden and Islington NHS Foundation Trust and Metropolitan Police Service
AI-generated concerns summaryThe tele-tracking system led to communication breakdown and confusion regarding appropriate patient transport, with unclear roles for doctors and nursing staff. Concerns were also noted about a lack of clear protocols for porters assisting patients and their awareness of patient fall risks.
Addressed to: Shrewsbury and Telford Hospital Trust
AI-generated concerns summaryThe coroner noted Mr Araujo's crisis team referral was closed without addressing risks, and an unacceptable two-week delay occurred in securing a Mental Health Act assessment despite an identified acute suicide risk.
Addressed to: AMHP; London Borough of Camden; Camden and Islington NHS Foundation Trust; Department of Health and Social Care; Home Office; Metropolitan Police Service; Royal Mail
AI-generated concerns summaryThe coroner raised concerns about the unmanned site's remote location and known trespassing by young people, highlighting the danger of deep, uncovered water channels lacking edge protection. Insufficient action has been taken to prevent access via an adjacent weir and reduce the risk to children.
Addressed to: Yorkshire Hydropower Ltd, Foresight Group, Wakefield Metropolitan District Council and The Canal and River Trust
Addressed to: Minister of State for Prisons and Probation and Cambridge University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the Christian Congregation of Jehovah's Witnesses (CCJW) does not have a safeguarding policy for vulnerable adult members, and their response to adopting one was unclear.
Addressed to: Christian Congregation of Jehova’s Witnesses
AI-generated concerns summaryConcerns included Greater Manchester Police not recording or investigating a sexual offence allegation, which affected victim support. There was also an absence of a clear multi-agency strategy for complex cases and insufficient alcohol misuse support for trauma-driven needs.
Addressed to: Greater Manchester Health and Social Care Partnership; Greater Manchester Police
AI-generated concerns summaryThe coroner noted the absence of restrictions on the import, export, possession, or administration of oral morphine, and that safe custody requirements and signing for collection from pharmacies do not apply.
Addressed to: Chair of the Advisory Council on the Misuse of Drugs and Minister of State for Mental Health, Suicide Prevention and Patient Safety
AI-generated concerns summaryA lack of a national therapeutic pathway for Personality Disorders was identified, alongside gaps in statutory provision of trauma-informed mental health services. Separate computer systems used by hospital and mental health liaison staff in Emergency Departments also risked information loss.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryNursing staff exhibited insufficient understanding to accurately diagnose hypostasis and rigor mortis, which management agreed needed better coverage in life support training. Additionally, definitions within the CPR guidance document for prisons were found to be confusing.
Addressed to: Practice Plus Group and Resuscitation Council UK