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 care home design allows residents with cognitive illnesses to freely leave the building unnoticed, as the main exit is unlocked during the day and there is no observation of the foyer area. This raises concerns about the suitability of the accommodation for individuals with such conditions.
Addressed to: Able Care and Support Services Ltd
AI-generated concerns summaryThe coroner noted the care home's 'Post-Falls' policy lacked clear direction on when to call emergency services for head injuries, specifically on distinguishing between 'possible' and 'suspected' injuries. There were also concerns about staff training in recognising intracranial injury.
Addressed to: Hampshire County Council and Oakridge House Residential Home
AI-generated concerns summaryThe coroner raised concerns that an e-book detailing how to end a life and lethal quantities of a substance are both available for unrestricted online purchase, noting a lack of protection for vulnerable individuals making these purchases.
Addressed to: Department of Health and Social Care; eBay UK Ltd
AI-generated concerns summaryThe coroner identified errors in CT scan interpretation and review, an improperly completed falls assessment, and a lack of staff training on assessing private equipment safety. Additionally, an adverse reaction to a Naso-Gastric tube was not recorded, which could affect future clinical decisions.
Addressed to: Royal Free Hospital
AI-generated concerns summaryThe coroner noted a lack of safety assessment for the patient's flat and its appliances during hospital discharge planning and via the Co-ordinate My Care Plan. Additionally, concerns were raised about the unmonitored fire alarm system in the flats.
Addressed to: East End Homes, East London NHS Foundation Trust and St Paul’s Way Medical Centre
AI-generated concerns summaryGRS operates vehicles with mirrors and guards positioned less than 2 meters from the road surface and projecting over 20 centimetres from the vehicle's widest point. This configuration is identified as creating a risk of personal injury and death to those overtaken by these vehicles.
Addressed to: GRS Recovery
AI-generated concerns summaryThe coroner noted an absence of national guidance for engaging with the families of mental health patients to obtain a comprehensive picture of their condition.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted that the pedestrian barrier was not robust enough to prevent individuals from accessing the track. Gaps were also identified in the wire fence along the viaduct parapet, and similar incidents have occurred previously.
Addressed to: LNER and Network Rail
AI-generated concerns summaryThe coroner noted that no summary of care is provided to GP practices when complex patients with extensive records transfer surgeries, which risks missing important clinical information. Handover summaries could improve continuity of care and prescribing safety.
Addressed to: Continuing Care; Continuing Care, Redbridge Clinical Commissioning Group and Royal College of General Practitioners; Redbridge Clinical Commissioning Group and Royal College of General Practitioners
AI-generated concerns summaryThe coroner noted that many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Concerns were also raised about the discrepancies and lack of clarity between different asthma management guidelines, leading to confusion among healthcare professionals and indicating a need for further training.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted insufficient reporting and sharing of information on food-related fatalities, identifying the lack of a national register and timely notification to the FSA. Concerns were also raised about the lack of official investigation into the feasibility of food businesses carrying adrenaline auto-injectors.
Addressed to: Department of Health and Social Care; Food Standards Agency; Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner noted a lack of a centralised, formulated risk document for patients detained under the Mental Health Act. Various risk assessments are conducted by different clinicians but are not consolidated, making it difficult for ward staff to review overall risk.
Addressed to: Oxleas NHS Trust
AI-generated concerns summaryPlastic bags were accessible to Tina Murray despite her identified risk to herself in relation to them. The coroner noted the importance of robust risk assessments and safety measures for residents with mental health conditions, dementia, and learning disabilities at Belgravia Care Home.
Addressed to: Belgravia Care Home Ltd
AI-generated concerns summaryThe coroner raises concerns regarding visibility and deterring right turns from a driveway near a blind bend. The report also notes questions about the appropriateness of the speed limit at that bend and the potential for a warning sign for the concealed driveway.
Addressed to: Highways England National Traffic Operations Centre
AI-generated concerns summaryThe coroner noted that fractures were not identified despite examination by three qualified staff members, possibly due to a shortage of radiologists. It is unclear what specific steps are being taken to prevent similar diagnostic errors.
Addressed to: Tameside General Hospital
AI-generated concerns summaryThe coroner raises concerns that council records may be contaminated with asbestos fibres, presenting a risk of exposure and mesothelioma to those who come into contact with them.
Addressed to: Lambeth Borough Council; West Sussex County Council
AI-generated concerns summaryMrs Dawkins' required renal monitoring, including blood tests and fluid monitoring, was not performed for four days, leading to an acute kidney injury. Additionally, the Trust's governance systems did not classify this as a Serious Incident requiring investigation for two years.
Addressed to: Department of Health and Social Care; Royal London Hospital
AI-generated concerns summaryA penicillin-type antibiotic was prescribed despite a recorded adverse reaction, with no evidence the clinician noted this or conducted a consultation. The report notes that entries for adverse reactions in medical records are not sufficiently highlighted for unfamiliar clinicians.
Addressed to: Tettenhall Medical Practice
AI-generated concerns summaryInformation that a patient had expressed suicidal feelings to a security guard was not reported to clinicians at the Acute Assessment Unit or Wedgwood ward, despite the guard's concerns.
Addressed to: West Suffolk Hospital and The Wedgewood Unit, Norfolk and Suffolk Foundation Trust
AI-generated concerns summaryThe coroner noted a GP did not recognise dehydration risk and had delayed notes, while a national tool used by newly qualified paramedics did not clearly prompt immediate hospital transfer for sepsis. Care home staff also lacked national guidance to recognise and escalate dehydration risk.
Addressed to: Care Quality Commission, Department of Health and Social Care