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 that reduced family contact during lockdown led to a lack of information for treating clinicians regarding a patient's health and events leading to admission, potentially hindering effective treatment for vulnerable individuals.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner notes that residential landlords are not currently required to inspect window coverings, such as roller blinds, in private rental properties or ensure that safety cords are used.
Addressed to: Ministry of Housing, Communities and Local Government
AI-generated concerns summaryContrast media, a prescription-only medicine, is administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients. There are no specific prescribing safeguards for patients with an eGFR lower than 30.
Addressed to: Queen’s Hospital
AI-generated concerns summaryThe coroner noted the absence of a local protocol within the Falls Policy for managing head trauma in anticoagulated patients over 65 who are also receiving Clexane for another clinical reason.
Addressed to: Princess Alexandra Hospital
AI-generated concerns summaryConcerns included a lack of follow-up on multi-disciplinary team recommendations, inaccurate malnutrition charting, delayed recognition of weight loss, and end-of-life decisions made without consulting key clinical teams.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryWhen internal mental health referrals are declined for insured patients, this information is not directly communicated to the patient but to insurers, potentially delaying their awareness of treatment options and safety netting advice.
Addressed to: Priory Group
AI-generated concerns summaryThe coroner raised concerns regarding the waiting times between chest x-ray and image review, and the need for a system to ensure prompt clinical review after a PEWS alert.
Addressed to: Barts and Whipps Trust
AI-generated concerns summaryThe coroner noted concerns regarding communication between teams, especially during night handovers, and the uncertainty over whether an effective communication tool (SBARD) for accurate information transfer was being used.
Addressed to: Norfolk and Norwich University Hospital
AI-generated concerns summaryThe coroner noted that the clinician conducting a telephone triage assessment was unfamiliar with the Trust's Operational Policy and Triage guidance, emphasizing the need for a robust system to ensure future clinicians are familiar with relevant documents.
Addressed to: Devon and Cornwall Constabulary; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted Group B Strep (GBS) was not discussed with the mother during pregnancy, preventing her from being aware of the infection's dangers. The report suggests the trust consider introducing a routine GBS screening program for all pregnant mothers.
Addressed to: Milton Keynes University Hospital
AI-generated concerns summaryThe coroner noted issues with staff not listening to family concerns, a lack of cleanliness, potential delays in antibiotic administration, and multiple omissions or delays in administering time-specific Parkinson’s medication.
Addressed to: Royal Cornwall Hospital
AI-generated concerns summaryThe coroner raised concerns regarding CQC inspections of GP practices, suggesting checks for domestic violence and safeguarding policies, staff training, and 'early warning systems' for uncollected prescriptions or cancelled appointments.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner noted the absence of a quality assurance system for discharge summary letters at Pennine Care NHS Foundation Trust. This led to an inaccurate discharge letter for Mr. Owen, which omitted crucial details about his risk and incidents during admission, and was not counter-checked by a senior clinician.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an identified need to ensure risk assessments for patients going on leave adequately identify community risks and detail staff actions if the plan breaks down.
Addressed to: Devon Partnership NHS Trust
AI-generated concerns summaryA rare blood condition diagnosis was not escalated to specialist consultants, and the automated VTE assessment system lacked robustness with no limit on manual overrides. Crucial decisions regarding prophylactic anticoagulation medication were also not clearly flagged in electronic patient records.
Addressed to: West Suffolk Hospital
AI-generated concerns summaryThe coroner raised concerns that the referral pathway for abdominal aortic aneurysms (AAAs) measuring 5.5cm or greater includes the GP's role as a potentially redundant link, which could lead to vital diagnostic information not being acted upon.
Addressed to: Clinisys UK; Maylands Health Care; Public Health England; Barking, Havering and Redbridge University NHS Trust
AI-generated concerns summaryThe coroner notes that standard class 5 and 6 mirrors on lorry cabs provide inadequate vision, creating an avoidable risk that drivers may not see other road users and pedestrians when stationary.
Addressed to: Department for Transport; Drivers and Vehicle Standards Agency
AI-generated concerns summaryCoroner noted a lack of formal agreements for urgent ophthalmic transfers and insufficient specialist ED review. Concerns also involved vital signs monitoring omissions, failure to follow deterioration review protocols, and incomplete documentation of prescribed treatments.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner questioned whether the DVLA's regulations concerning driving licences for individuals with epilepsy, specifically the timeframes for licence surrender, should be reviewed following an incident possibly triggered by an epileptic seizure.
Addressed to: Department for Transport; Secretary of State for Transport's Honorary Medical Advisory Panel on
AI-generated concerns summaryThe coroner raised concerns about the NHS's ability to provide suitable places of safety for patients with autism and co-occurring mental health conditions. The Campbell Centre was deemed inappropriate, highlighting a need for more appropriate provision.
Addressed to: NHS England