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 a delay in activating motorway warning signals and noted communication issues between Highways England and the North West Motorway Police Group. No internal review of the accident circumstances was undertaken by Highways England.
Addressed to: Highways England; North West Motorway Police Group
AI-generated concerns summaryThe coroner identified deficiencies in decision-making and access to secondary mental health care, particularly for dual diagnosis patients. Concerns also included insufficient liaison with family and a misunderstanding of the patient's autistic presentation during assessment.
Addressed to: GP; GP, Change Grow Live, Nottinghamshire Healthcare NHS Foundation Trust and Nottinghamshire County Council
AI-generated concerns summaryThe coroner noted that family concerns about a patient's reported suicide attempt were not recorded, shared, or acted upon, nor included in the MDT meeting. There were also unmitigated ligature risks identified in an en-suite bathroom following an assessment.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust, Care Commissioning Group for Birmingham and Solihull, Care Quality Commission and Health and Safety Executive
AI-generated concerns summaryConcerns included updating sepsis guidance and mandatory training for staff, and reviewing timely antibiotic prescribing due to potential over-caution. The coroner also noted that family contact details should be actively obtained at hospital admission and discharge.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the absence of practical clinical reference tools at Specsavers, leading a practitioner to rely on Google for decision-making. There was also no formal mechanism for sharing clinical incident learning among practitioners.
Addressed to: Specsavers UK
AI-generated concerns summaryThe coroner identified a lack of a multidisciplinary approach to managing Mr. Jones' increasing confusion and high falls risk, noting that required supervision levels were not met due to insufficient staffing. This contributed to multiple falls, reflecting a failure in the falls prevention strategy.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted inconsistent routine testing of magnesium levels in transplant patients on tacrolimus across different NHS trusts, despite the known life-threatening side effect of reduced magnesium. This variability means patients may not be regularly monitored.
Addressed to: NHS England
AI-generated concerns summaryConcerns were raised regarding discharge arrangements where the lead practitioner and parents were not informed, and the accommodation provided was unsuitable for a person with recognised mental health and substance misuse difficulties.
Addressed to: Horsham District Council
AI-generated concerns summaryThe coroner identified a lack of permission-seeking for family contact, an outdated medical alert affecting detention decisions, and the absence of a formal mental health assessment or care coordinator for Mr O'Hara.
Addressed to: Camden & Islington NHS Foundation Trust (C&I); St Pancras Hospital
AI-generated concerns summaryInefficient processes led to a patient being lost to follow-up, with national guidance for the Care Programme Approach not being followed. Additionally, the trust had a fragmented policy application across different geographic areas, leading to staff unawareness of procedures elsewhere.
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that policing plans developed by Greater Manchester Police to prevent large illegal gatherings, following an event where no clear plan existed, may not have been shared and embedded in other police force areas.
Addressed to: Home Office; National Police Chiefs Council
AI-generated concerns summaryThe DVT risk assessment conducted upon admission did not adequately consider Ms Grant's significant risk factors, such as obesity, inactivity, and a medication side effect, leading to no further treatment for the condition.
Addressed to: Dept. of Health and Social Care, Black Country Partnership NHS Foundation Trust and CQC
AI-generated concerns summaryThe coroner noted insufficient nursing staff levels impacted patient supervision and nurses' ability to take full breaks. Furthermore, front-line nursing staff had not received the findings of the internal investigation into the patient's death.
Addressed to: Aneurin Bevan University Health board
AI-generated concerns summaryNon-clinical staff significantly influenced decisions regarding patient leave, leading clinical staff to feel unable to object. There was also a persistent lack of psychologist input on the ward for over three years.
Addressed to: South West Yorkshire Partnership
AI-generated concerns summaryThe coroner raised concerns regarding the failure to undertake required patient observations, which was linked to low nursing staff numbers, reliance on agency nurses, and a lack of staff experience and equipment on the ward.
Addressed to: Medway Maritime Hospital
AI-generated concerns summaryNo specific concerns were detailed in the provided text.
Addressed to: Brighton Sussex University NHS Hospital Trust, West Sussex NHS Hospital Trust and Medico-Legal
AI-generated concerns summaryEngland Boxing lacked adequate and enforceable child protection and safeguarding measures, along with a policy for checking compliance. This resulted in outdated welfare officer information and registered inactive coaches at a club.
Addressed to: Department for Culture, Media and Sport; England Boxing
AI-generated concerns summaryThe coroner raises concerns that the measures taken by the Isle of Wight Council, specifically hedge realignment, do not go far enough to address the safety of a junction with a history of serious road traffic collisions and poor visibility.
Addressed to: Highways – Isle of Wight Council and Ringway Island Roads Ltd
AI-generated concerns summaryThe coroner noted poor record-keeping, particularly during night shifts, which hindered day staff's understanding of residents' overnight status. Concerns were also raised regarding the night shift's care delivery, where staff could be unaware of vulnerable residents needing assistance.
Addressed to: Riverside Rest Home
AI-generated concerns summaryThe coroner was not satisfied that New Lodge Nursing Home had robust systems in place to ensure compliance with care plans, policies, and protocols.
Addressed to: New Lodge Nursing Home