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 Health and Justice Team used different software from other EPUT teams, preventing important mental health information and crises from being shared. This could lead to other teams being unaware of crucial details, potentially resulting in inaccurate risk assessments for individuals.
Addressed to: Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of professional guidance and training for midwives performing a 'vaginal push' to disimpact the fetal head in theatre. Concerns were also raised about the inconsistent understanding and absence of guidance on using fetal pillows.
Addressed to: Royal College of Nursing and Midwifery; Royal College of Obstetrics and Gynaecology
AI-generated concerns summaryThe coroner noted patient information was dispersed across multiple systems, Trust head injury policies diverged from NICE guidelines, and anticoagulation guidelines lacked coverage for preventative measures. The falls form also did not direct doctors to relevant head injury guidance.
Addressed to: NHS England; University Hospital of Derby and Burton
AI-generated concerns summaryThe coroner raised concerns regarding the overall bed capacity for patients seeking informal mental health admission and the lack of provisions to temporarily house such patients when a bed is not immediately available.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe report identifies a missed opportunity for an independent assessment of the driver's ability following a prior collision, noting the lack of a driver referral scheme for elderly individuals within the relevant police force to facilitate such evaluations.
Addressed to: South Wales Police
AI-generated concerns summaryThe coroner noted inadequate initial critical analysis of deaths, risking missed learning opportunities. The report also highlights an unsafe culture within Midwifery Services, including unaddressed staff safety concerns, poor risk management, and insufficient clinical oversight.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified difficulties in sharing safeguarding information between the GP, other agencies, and care homes due to GDPR requirements and the absence of a consent mechanism or central information hub.
Addressed to: Suffolk Safeguarding Partnership; Limes Sheltered Housing
AI-generated concerns summaryThe coroner identified delays in obtaining neurosurgical input and expediting a CT scan for a head injury patient on warfarin, noting an absence of clear systems for fast-tracking such cases. Further concerns included a delay in seeking follow-up haematology advice.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted ongoing uncertainty regarding how and why anticoagulant prescription errors occurred, raising concerns that similar errors could recur due to multiple prescribing documents. There is a need for senior review and clear prescription plans, as an electronic system alone might not ensure adequate oversight.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a routine MRSA swab on hospital admission for certain patient groups, which delayed the early identification of infection. This practice could impact outcomes in cases requiring emergency surgery with postoperative infection.
Addressed to: Greater Manchester Health & Social Care Partnership; Healthcare Safety Investigation Branch
AI-generated concerns summaryThe coroner noted confusing "SLOW" road markings on the A689, appearing immediately after 30mph zones change to 60mph limits. There is also a lack of warning signs or double white lines at a bend with reduced visibility on the same road.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted gaps in CRG's procedures for obtaining information from a secure unit following a prisoner's discharge, which meant the prisoner did not receive prescribed medication or full discharge details including diagnoses and care plans.
Addressed to: Essex Partnership University NHS Foundation Trust; Castle Rock Group
AI-generated concerns summaryRedundant television brackets in HMP Garth cells, including the deceased's, remain in place and constitute ligature points. These will continue to be a risk until removed.
Addressed to: HMP Garth
AI-generated concerns summaryThe coroner noted a fatal fall from a public footpath near a severe drop and a viewing spot. There was a concern that safety-related signage could alert members of the public to the danger.
Addressed to: Calderdale Council
AI-generated concerns summaryDelays in the system for cardiology test referrals resulted in slower completion of tests and postponed patient referrals to the cardiology clinic.
Addressed to: NHS Stockport Clinical Commissioning Group
AI-generated concerns summaryConcerns were raised regarding easily accessible non-food items for a resident lacking insight, an unescalated prior incident of ingesting non-food items without risk assessment, and the absence of sensors to alert night staff to residents wandering.
Addressed to: Care Quality Commission; Meade Close Care Home; NHS Trafford Clinical Commissioning Group; Trafford Metropolitan Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding insufficient checks, documentation, and assessment of pressure areas and wounds. Further issues included a pressure mattress being turned off, a lack of staff escalation, and inadequate involvement of GPs and Tissue Viability Nurses.
Addressed to: Beechdene Residential Home; Leek Health Centre; Midlands Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a two-hour wait for an emergency ambulance and that the family was not informed of the expected arrival time. Concerns also included significant delays in transferring patients to hospital, preventing ambulance release.
Addressed to: Aneurin Bevan University Health Board; Welsh Ambulance Services NHS Trust
AI-generated concerns summaryConcerns were raised about acute bed shortages causing a frail patient to wait over 24 hours in A&E, and delays in providing a care package post-discharge, which contributed to deconditioning.
Addressed to: Department of Health and Social Care; Greater Manchester Health & Social Care Partnership; Healthcare Safety Investigation Branch
AI-generated concerns summaryPackaging for intravenous fluids used with arterial line transducer sets lacks distinctiveness, leading to errors. Additionally, medical staff were not using the correct technique when drawing blood samples from arterial lines, which compounded the issue.
Addressed to: Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency