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 hospital did not order formal observations for an intoxicated patient, and nurses were not given instructions or training on how to avoid positional asphyxia, an issue commonly addressed in custodial settings.
Addressed to: Weymouth Street Hospital
AI-generated concerns summaryThe iCope service does not routinely ask patients for consent to involve their family in their mental health situation. Additionally, a required 72-hour investigation report was completed with a significant delay of five months.
Addressed to: St Pancras Hospital
AI-generated concerns summaryThe coroner raises concerns that the absence of a hard shoulder on the 'All Lanes Running' section of the M1 motorway creates a risk of future deaths, as vehicles with mechanical defects have no safe place to stop.
Addressed to: Highways England
AI-generated concerns summaryThe coroner raised concerns about a technical issue with the EMIS system which caused GP consultation lists not to update, leading to missed telephone appointments and a risk to patients. Mitigation strategies implemented to address this widespread issue are vulnerable to human error.
Addressed to: Ashfield Surgery Sutton Coldfield; Birmingham and Solihull Clinical Commissioning Group; EMIS; NHS England
AI-generated concerns summaryThe coroner noted that a patient's discharge summary, including medication details, was not received by her GP practice due to the omission of the practice name and an incorrect identifier, despite the correct NHS number.
Addressed to: Whiston Hospital
AI-generated concerns summaryTurner Ward at Goodmayes Hospital did not accurately record or file important medical records, including discharge decisions and risk assessments. There was also an ineffective referral process for patients from the ward to the community home treatment team.
Addressed to: Department of Health and Social Care; North East London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate training of medical professionals regarding eating disorders, specifically Anorexia Nervosa, including inconsistent implementation of treatment guidelines. There is also a continuing shortage of eating disorder specialists across the country.
Addressed to: SoS for Health and Social Care, NHS England, General Medical Council, Academy of Medical Medical Royal Colleges and Health Education England
AI-generated concerns summaryThe coroner identified an ineffectual system for detecting adverse outcomes in patients transferred to tertiary centres. Concerns were also raised about a seriously deficient internal case review, and failures in sepsis management and expediting urgent scans.
Addressed to: East Lancashire Hospitals NHS Trust
AI-generated concerns summaryThe MPDS script and algorithm did not adequately recognise a life-threatening asthma attack, failing to account for cumulative symptoms or proactively elicit details on ineffective breathing. NWAS consistently failed to meet Category 2 response targets.
Addressed to: NHS England and NHS Stockport Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted gaps in police training regarding the assessment of intoxicated individuals, particularly understanding the significance of snoring and how to monitor breathing. There is also a lack of facilities to which police can refer acutely intoxicated homeless people.
Addressed to: City of London Police, Metropolitan Police Service, College of Policing Units and Mayor of London
AI-generated concerns summaryThe coroner identified that Delivery Point Risk Assessments (DPRAs) do not mandate documenting views from store owners or drivers, and their mitigating measures do not adequately address pedestrian risks in vehicle blind spots during reversing maneuvers without specific aids. It was also noted that risk assessors should consider current driving …
Addressed to: DHL Supply Chain UKI
AI-generated concerns summaryThe deceased was not advised about the impact of his medical conditions and medications on driving safety or the legal requirement to notify the DVLA. Additionally, the medical practice did not inform the DVLA of these conditions.
Addressed to: Emsworth Surgery
AI-generated concerns summaryThe coroner noted that total body potassium depletion in children with myopathies, often presenting with gastrointestinal symptoms, is not always recognised, requiring more intensive treatment than standard approaches and specific monitoring considerations.
Addressed to: Dept. of Health, Royal College of GPs and Medway NHS Foundation Trust
AI-generated concerns summaryThe deceased was incorrectly prescribed Tazocin when colonised with ESBL, contrary to trust guidelines, and this error was not identified during multiple medical reviews.
Addressed to: Royal Stoke University Hospital
AI-generated concerns summaryThe coroner noted that mental health clinicians did not consider hormonal factors as a potential contributor to a peri-menopausal patient's depressive illness. It was also noted that NICE guidelines do not currently recommend routine hormone monitoring or considering this factor in such cases.
Addressed to: Institute for Health and Care Excellence; National General Medical Council; Southern Health NHS Foundation Trust of Tatchbury Mount
AI-generated concerns summaryThe coroner identified a lack of referral to a tissue viability nurse for a Category 3 pressure ulcer, insufficient protocols for agency nurses, and no system to coordinate district nurse and carer visits, which resulted in incomplete patient care.
Addressed to: Whittington Hospital
AI-generated concerns summaryThe coroner noted that Jaden's deteriorating mental well-being was not recognised, preventing access to available support. The report highlights the importance of recognising subtle signs of distress and exploring a request for help that is subsequently not utilised.
Addressed to: London Fire Brigade
AI-generated concerns summaryThe ambulance service took 3 hours and 10 minutes to respond to a paracetamol overdose, which clinicians considered a time-sensitive emergency. Concerns were raised regarding the justification for not conducting a Serious Incident Report for this delay.
Addressed to: South East Coast Ambulance Service and Medical Directors
AI-generated concerns summaryThe coroner raised concerns regarding inadequate police officer training for monitoring detainee health, insufficient paramedic leadership and integration in detention situations, and ineffective application of the Safety Officer role during restraint incidents. Serious inadequacies were also noted in supervision and risk assessment processes.
Addressed to: London Ambulance Service; Metropolitan Police Service
AI-generated concerns summaryThe coroner noted that other doctors and dispensing pharmacists did not contact the patient's registered GP about opiate prescriptions. There is also no formal national procedure for circulating patient alerts to pharmacies, limiting their effectiveness.
Addressed to: Primary Medical Services and Integrated Care – Care Quality Commission and Minister of State for Patient Safety