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 raised concerns regarding the delayed or non-existent transfer of patient data between GP practices, alongside the lack of electronic access to regular GP records for out-of-hours doctors, which particularly impacts vulnerable patients and can hinder medical assessment.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted concerns regarding Mr Collins' prolonged stay in an acute hospital due to the challenges of finding a suitable EMI placement. This delay was largely attributed to a lack of appropriate complex EMI beds locally and nationally, impacting the availability of acute hospital beds.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner identified significant pressures in the Emergency Department, resulting in a patient being treated in a corridor and delays in a procedure and transfer to a surgical ward due to competing demands and bed capacity.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner noted the deceased consumed Dinitrophenol (DNP), a drug banned since 1938, which was likely accessed via the internet due to social media influence for body image improvement.
Addressed to: Department for Digital, Culture, Media and Sport
AI-generated concerns summaryThe coroner identified discrepancies in a doctor's evidence regarding cervical dilation and the rationale for proceeding to an early delivery, conflicting with other medical opinions and expert advice. Concerns were also raised about the doctor's subsequent handling of the delivery procedure and refusal of consultant assistance.
Addressed to: James Paget University Hospital; RadcliffesLeBrasseur LLP
AI-generated concerns summaryUK mental health services did not adequately review or understand overseas medical information, including the Australian equivalent of 'Sectioned' status, which contributed to a downgraded referral and poor inter-departmental communication.
Addressed to: Berkshire Healthcare NHS Foundation Trust
AI-generated concerns summaryGPs did not use the approved referral form for psychiatric presentations to the Midland Partnership Foundation NHS Trust, which could lead to incorrect prioritisation of future referrals.
Addressed to: Midlands and Lancashire Commissioning Support Unit; Stafford and Surrounds Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted prolonged waits and unsuitable conditions for elderly patients in the Emergency Department due to capacity issues and delayed discharges. Short staffing from nurse shortages and deprioritised fall risk assessments further increased patient risks.
Addressed to: Department of Health and Social Care; Greater Manchester Health and Social Care Partnership
AI-generated concerns summaryThe coroner raised concerns about an unlit dual carriageway lacking a footpath, where pedestrians are foreseeable, noting that their visibility distance was significantly less than a vehicle's emergency stopping distance. Safety improvements for this road were previously recommended.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted that ambulance calls from residential facilities where contact cannot be established are automatically categorised as Category 4. There is also a lack of clarity regarding expectations for updates once a call has been placed by a call centre.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that suicide intervention training provided to new police recruits in Sussex Police is not being rolled out to all front-line staff.
Addressed to: Sussex Police
AI-generated concerns summaryThe coroner raised concerns regarding whether monitoring blood levels of powerful antipsychotics should be considered for patients on long-term high-dose treatment, particularly as they become older and more frail.
Addressed to: Medicines and Healthcare Products Regulation Agency; North Cumbria University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the need for improved interagency working and information sharing. Concerns were also raised regarding a crisis team clinician's lack of contemporaneous records and undocumented decision-making rationale, including capacity assessment details.
Addressed to: North West Boroughs Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted professionals discounted symptoms without adequate investigation or addressing GP concerns, leading to discharge without psychiatric follow-up. The Root Cause Analysis subsequently failed to identify these care problems.
Addressed to: Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that issues with patient handover to midwives persisted without changes or specific training one year after the death. Furthermore, a team debrief remained outstanding, and there was insufficient evidence of effective reflection or learning.
Addressed to: St. George’s University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a 2.5-day delay in resuming Dalteparin due to a weekend, raising concern that such delays could lead to preventable deaths in other patients.
Addressed to: Great Western Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns about the safety of a road junction, following multiple collisions, specifically regarding the U-turn manoeuvre across the carriageway, and requested the Council to review its safety.
Addressed to: Liverpool City Council; Merseyside Police
AI-generated concerns summaryA cluster of student deaths from a particular bridge, including three this year and four in two years, was identified as a specific concern.
Addressed to: Suspension Bridge Trustees
AI-generated concerns summaryThe coroner identified an incorrectly reported smear test and multiple occasions where clinically obvious cervical cancer or the need for further assessment was not recognised. A guide for managing abnormal cervix conditions, which the Trust later developed, was not in place at the time.
Addressed to: Department of Health and Social Care; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner raises concerns that current legislation places the responsibility on drivers with dementia to inform the DVLA, which may not always occur. It is suggested that public interest could be better served by legislation requiring direct referral of such diagnoses from medical professionals to the DVLA.
Addressed to: Department for Transport