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 identified inadequate post-operative monitoring and a failure to escalate a frail patient's deteriorating condition, despite signs like low blood pressure. Concerns were raised regarding unclear escalation procedures for junior staff and the absence of information on implemented changes.
Addressed to: Leeds Teaching Hospital NHS Trust
AI-generated concerns summaryThe coroner identified a lack of DWP call handler training for mental ill health interactions, and that call records were brief and inaccurate. Concerns were also raised about the assessment process, which did not allow for correcting errors or cancelling appointments without prejudice.
Addressed to: Capita; Department for Work and Pensions
AI-generated concerns summaryThe coroner identified a lack of widespread appreciation for the risks posed to epilepsy sufferers by inward-opening doors in confined spaces. An outward-opening door might have prevented the death.
Addressed to: President of Association of British Neurologists, Chief Executive of Epilepsy Action and President of the Royal College of Paediatrics and Child Health
AI-generated concerns summaryStaff at St Catherine’s Priory and other Approved Premises may not be familiar with or applying the Safe Working Practices Document, specifically the guidance on prescribed medication delivery/collection and other resident safety policies.
Addressed to: HMPS
AI-generated concerns summaryConcerns included a lack of clear clinical responsibility for long-stay A&E patients, failure to conduct mandated clinical reviews based on EWS scores, and a lack of escalation by nursing staff. The Trust's own investigation was also deemed inadequate.
Addressed to: Care Quality Commission; East Lancashire Hospitals NHS Trust
AI-generated concerns summaryGreater Manchester Police did not record an assault with a weapon as a crime, impacting the provision and signposting of appropriate victim support for the individual with known vulnerabilities.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe care home lacked clear guidance and sufficient staffing to manage falls risk for isolated residents, leading to inadequate observation. This, combined with unsupported hospital transfers for vulnerable patients, hindered effective communication and clinical decision-making.
Addressed to: Care Quality Commission; Department of Health and Social Care
AI-generated concerns summarySignificant delays in accessing psychology services and a lack of local mental health inpatient beds were identified. The coroner also noted health professionals' reluctance to gather family information due to a misunderstanding of patient confidentiality.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe ambulance service's call handling script did not adequately provide realistic ambulance arrival times or discuss alternative transport during busy periods. It also lacked emphasis on selecting an acute hospital for direct transfer and the importance of re-calling if the patient deteriorated.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raises concerns that if cell electricity issues are not resolved until the following day after lockdown, this could create a risk of prisoners harming themselves, suggesting basic maintenance availability during lockdown hours.
Addressed to: HMP Dovegate
AI-generated concerns summaryThe coroner identified a culture of positive risk-taking regarding suicidality within the Trust, alongside gaps in staff training for suicide risk assessment, engagement with families, and appropriate communication with patients.
Addressed to: Acute Mental Health Services, West London NHS Trust
AI-generated concerns summaryHaringey Children’s Services facilitated the discharge of Lily-Mai into her parents' unsupervised care despite professional opposition. A subsequent decision for residential placement was not implemented before she suffered fatal injuries.
Addressed to: Children’s Services, Haringey Council
AI-generated concerns summaryThe 'immediate needs' form at HMP Belmarsh does not clearly assess self-harm or suicide risk for prisoners without an existing care plan. There is also no robust system to audit nightly roll checks, which means they may not be completed.
Addressed to: HMP Belmarsh and HMPS
AI-generated concerns summaryThe EMIS computer medical record system did not alert medical staff to a duplicate patient registration, leading to an inadvertent duplication of morphine prescriptions.
Addressed to: Long Furlong Medical Centre
AI-generated concerns summaryCare Outlook staff did not resolve the faulty heating in Mr O'Neill's flat during a heatwave. They also did not ensure his adequate rehydration, and his deterioration was not recognised.
Addressed to: Care Outlook Ltd
AI-generated concerns summaryHospital policy on the roles of primary and second midwives and anaesthetists during epidural siting does not reflect practice, raising concerns about clarity for fetal monitoring. Further guidance is needed on the 'fresh eyes' concept for staff support and improved outcomes.
Addressed to: Portland Hospital
AI-generated concerns summaryThe coroner noted that clinicians did not complete a suspected cancer upgrade form and the pathology report was not communicated to the GP upon discharge. This, along with insufficient consideration of medical records, led to a delayed referral for chemotherapy.
Addressed to: Northern Care Alliance NHS Trust
AI-generated concerns summaryOxford University lacks an overarching drug policy for its colleges, and St John's College has a potential conflict between its strict drug misuse policy and the support offered for addiction, which may deter students from seeking help. The college's drug policies also require wider advertisement.
Addressed to: St John’s College, Oxford University
AI-generated concerns summaryThe coroner noted a lack of evidence regarding the company's occupational health checks for employees exposed to hazardous substances and high-risk practices. There was also no evidence of compliance with HSE guidelines (G404) for respirable crystalline silica, including advising employees of risks and conducting health surveillance.
Addressed to: Marble Ideas Ltd
AI-generated concerns summaryInadequate discharge planning included no home assessment, insufficient family notification, and incomplete notes. Concerns were also raised about no district nurse referral for leg ulcers and a safeguarding alert not being acted upon after unsafe home conditions were found.
Addressed to: Adult Safeguarding Kent County Council; Medway NHS Foundation Trust