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 a lack of evidence that Mrs Willcock's chest was auscultated during her A&E visit after fainting and falling, or during a subsequent day surgery. This meant a potential new heart murmur, which should have prompted an immediate cardiology referral, was not identified.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that inhaling butane is lawful with no powers to intervene, and there are no restrictions on the amount that can be purchased, making it easy for addicted individuals to obtain large quantities.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryConcerns were raised regarding Stars Social Support Limited's lack of transparency and inadequate policies for communicating care plan updates to all staff. The over-reliance on WhatsApp for this purpose created safeguarding risks and left visiting professionals without critical information.
Addressed to: Stars Social Support Ltd, Care Quality Commission and South West Yorkshire Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a requirement for regular lung imaging in patients prescribed long-term amiodarone, despite the medication's potential to cause lung toxicity and fibrotic changes.
Addressed to: Royal College of GPs; Royal College of Physicians
AI-generated concerns summaryConcerns included the electronic notes system's inability to upload PDF medical records and difficulties printing in shared premises. The coroner also noted an incomplete patient safeguarding risk assessment process and unassured ligature point inspections.
Addressed to: Tees, Esk and Wear Valley NHS Foundation Trust; Department of Health and Social Care; SoS for Health and Social Care and West Park Hospital; West Park Hospital
AI-generated concerns summaryThe Care Programme Approach process between the local authority and NHS Trust remained unresolved after five years. Concerns were also raised that a person with psychological illness could not register with a GP due to a lack of documentary proof, limiting access to support.
Addressed to: Central and North West London NHS Foundation Trust and NHS England
AI-generated concerns summaryThe care home did not apply its falls risk assessment and prevention policies, missing opportunities to reassess the resident's risks after three falls. There was a lack of timely reporting to regulatory bodies and delayed commencement of staff supervision regarding falls prevention.
Addressed to: Care Quality Commission; Widnes Hall Care Home
AI-generated concerns summaryCancelled hospital appointments for vulnerable prisoners place them at risk. The coroner suggested investigating the possibility of special prison clinics with visiting consultants to address this.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a lack of accessible water rescue aids and safety warnings at a natural attraction, where steep banks and rocks made access difficult for rescuers. There was insufficient awareness of risks like cold water, current speed, and underwater obstructions.
Addressed to: Craven District Council, Yorkshire Dales National Park and Yorkshire Water
AI-generated concerns summaryConcerns were raised about the application of the Care Programme Approach policy for detailed discharge care plans and the timely allocation and engagement of care coordinators with inpatients and their support networks.
Addressed to: Oxford Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need to update the Accident and Emergency patient notes system at two hospitals within the trust. Concerns were also raised about ensuring regular note completion and providing staff training on the importance of accurately recording and evaluating patient conditions.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified insufficient training for medical students and junior doctors in taking bloods from central lines, coupled with a lack of formal competency assessment, standard operating procedures, and a system for handing over skills between wards.
Addressed to: Aston Medical School; Birmingham Medical School; Department of Health and Social Care; General Medical Council; Sandwell and West Birmingham Hospitals NHS Trust; UK Foundation Programme
AI-generated concerns summaryThe CERNER system does not consistently ensure results reach the referring clinician, sometimes sending them to uninvolved doctors. Radiologists lack confirmation that urgent reports have reached the appropriate clinician.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner identified that 1:1 care, which was the only way to mitigate Mrs Stillwell's high risk of falls, was not authorised by the Commissioner for her care.
Addressed to: Department of Health and Social Care; Havering Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted Pirton Grange lacked a robust policy for investigating staff misconduct, including imposing suspensions and reporting to the NMC. Following a death, initial investigation and reporting of nurse conduct to the NMC were inadequate and delayed.
Addressed to: Care Quality Commission; Field Fisher Solicitors; Holmleigh Care Homes Ltd; Plexus Law
AI-generated concerns summaryThe coroner identified a lack of internal investigation by the nursing home to review falls risk assessments and policies following the death. Concerns included unrecorded preceding falls, failure to update risk assessments, and misleading observation logs.
Addressed to: Cole Valley Care Ltd
AI-generated concerns summaryThe coroner raises concerns about the lack of national guidance for routine observation assessments of mothers and babies after hospital discharge, and for the medical assessment of a baby when its mother is admitted to hospital with potential sepsis.
Addressed to: Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health and National Institute of Clinical Excellence
AI-generated concerns summaryConflicting opinions among senior A&E consultants at Milton Keynes University Hospital regarding the importance of elevated lactate levels and adherence to NICE sepsis guidelines raised concerns for patient safety.
Addressed to: Milton Keynes University Hospital
AI-generated concerns summaryThe coroner noted that the patient's General Practitioner was not involved in the serious untoward incident investigation, despite the patient being under community care. This raised concerns about learning opportunities and better partnership working in such reviews.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner identified gaps in the proficiency of care and nursing staff regarding post-fall patient management, including interaction with ambulance services and accurate recording of vital signs. A review of staff training on these areas and awareness of fall complications is recommended.
Addressed to: Hart Care Nursing and Residential Home