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 identified concerns regarding Castlehill's adherence to falls management policies, including failures to refer Mr Bird to physiotherapy and to call 999 after falls. Delays in emergency service access, insufficient updates to falls care plans, and a lack of analysis regarding his increasing fall risk were also noted.
Addressed to: Care Quality Commission; Castlehill Specialist Care Centre
AI-generated concerns summaryThe coroner identified a significant gap in mental health service provision in Norfolk and Waveney for patients identified as At Risk Mental State (ARMS). These patients, despite high risk, did not meet criteria for existing services and consequently received no appropriate care.
Addressed to: NHS Norfolk; Waveney Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised systemic concerns about widespread misdiagnosis of thoracic aortic dissection due to a lack of awareness and education among clinicians. Questions were also raised regarding the adequacy of current decision-making and risk-scoring tools for diagnosis.
Addressed to: Barts Health NHS Trust; North East London NHS Foundation Trust; Royal College of Emergency Medicine; Royal College of Emergency Medicine, Barts Health NHS Trust and North East London Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of warning signs on Tubbon Hill for the junction with Trebost Lane, highlighting limited visibility and that vehicles must almost stop to make the acute turn.
Addressed to: CORMAC – Cornwall Council – Highways Department
AI-generated concerns summaryThe coroner noted a lack of inter-agency information sharing for complex cases and no defined escalation process in the care home for residents refusing medication. Concerns were also raised about discharge protocols failing to ensure a care home's capacity to accept a patient.
Addressed to: SoS of Health and Social Care, Greater Manchester Health and Social Care Partnership and Care Quality Commission
AI-generated concerns summaryThe coroner identified a chronic shortage of falls alarm equipment at Medway Maritime Hospital. This compromises clinical staff's ability to reduce patient fall risks, increasing the likelihood of patients sustaining fatal or serious injuries.
Addressed to: Medway Maritime Hospital
AI-generated concerns summaryThe prison lacked effective systems for emergency ambulance exit, leading to delays in authorization for Mr. Paget's transfer to hospital. There is a need for efficient, tested systems in prisons to manage emergency ambulance access and departure.
Addressed to: HMP Leeds
AI-generated concerns summaryInadequate discharge planning from the Abraham Cowley Unit included no confirmed housing, formal risk assessment, or sufficient observation of medication effectiveness prior to discharge. Gaps were noted in policies for post-discharge medical reviews and comprehensive community care coordination.
Addressed to: Surrey and Borders Partnership
AI-generated concerns summaryDifficulties arise in accessing consistent secondary psychiatric care for individuals residing near county boundaries where services are split, potentially impacting the quality of treatment.
Addressed to: St George’s Hospital
AI-generated concerns summaryThe coroner noted an Enteral 14FR tube's en-fit connector restricted its effective bore, causing insufficient drainage, raising concerns about inadequate product description, insufficient manufacturer and hospital evaluation, and nursing staff not aspirating tubes.
Addressed to: Enteral (GB) UK, University Hospital of North Midlands, Nursing Times, NHS England and ISO Standards Agency; MHRA; NHS Supply Chain
AI-generated concerns summaryCoroner noted insufficient product description and sales staff training regarding an enteral tube's restricted bore, impacting hospital evaluation and nursing staff's response to drainage issues. Concerns also highlighted the product's continued promotion despite safety notices.
Addressed to: Enteral (GB) UK, University Hospital of North Midlands, Nursing Times, NHS England and ISO Standards Agency; Industry Groups; Supply Chain Stakeholders
AI-generated concerns summaryThe coroner noted national Particulate Matter limits exceed WHO guidelines, alongside low public awareness of air pollution information and insufficient communication of health effects by medical professionals to patients and carers.
Addressed to: British Thoracic Society; Department for Environment, Food and Rural Affairs; Department for Transport; Department of Health and Social Care; General Medical Council; Health Education England; London Borough of Lewisham; Mayor of London; National Institute for Health and Care Excellence; Nursing and Midwifery Council; Royal College of General Practitioners; Royal College of Paediatrics and Child Health; Royal College of Physicians; Transport for London
AI-generated concerns summaryThe coroner noted a vehicle was in service despite multiple critical defects, including a worn rear tyre, a fractured rear arm pivot, and missing indicator lamps, which should have led to its immediate prohibition.
Addressed to: Ceredigion County Council and Bucher Municipal Ltd
AI-generated concerns summaryThe coroner noted a lack of a clear plan for antibiotic intervention and delayed initiation of treatment for a patient at high risk of infection. Additionally, it was unclear from medical records when a critical antibiotic was administered during septic shock.
Addressed to: University Hospital Lewisham
AI-generated concerns summaryThe coroner highlighted concerns about the existing road layout and whether it meets regulations, along with the need to consider measures for highlighting the commencement of the kerb to motorists.
Addressed to: Roads and Highways – Kirklees Council
AI-generated concerns summaryThe coroner noted a lack of cohesive national guidance across health and social care regarding the suspension of domiciliary care packages. Concerns were also raised about the absence of specific rules for agencies to convey information when vulnerable patients are discharged from urgent care settings without formal admission.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe Trust lacks a reliable system to provide service users with direct, tailored communication about their mental health referral status and plan, with pro-forma letters failing to account for their specific needs and potentially affecting their mental health.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner highlighted the critical need for hotels to maintain accurate, readily accessible lists of guests and staff to ensure emergency services can quickly access vital information and avoid delays in rescue efforts.
Addressed to: Dept. for Business, Energy and Industrial Strategy
AI-generated concerns summaryPatients undergoing endoresection surgery were not fully informed of death risks from air embolus, lacked post-operative checks, and were not advised to stay overnight for essential monitoring and potential swift transfer.
Addressed to: Moorfields Eye Hospital NHS Foundation Trust
AI-generated concerns summaryMental Health Services made inadequate arrangements to protect the individual despite her expressing an immediate plan to harm herself, and made no attempt to contact her for safety or support. The coroner noted a lack of assurance regarding measures to contact individuals communicating immediate risk of harm.
Addressed to: Betsi Cadwaladr University Health Board; Wrexham County Borough Council