Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted significant delays in a patient seeing a doctor after ward admission and further delays in receiving intravenous fluids and antibiotics, which may have reduced the chance of survival.
Addressed to: North Cumbria Integrated Care Trust
AI-generated concerns summaryThe coroner identified poor record keeping and insufficient, inaccurate pre-admission information, which resulted in an inadequate fall risk assessment. Additionally, discrepancies between medication charts and actual medication held were not detected by monthly drug audits.
Addressed to: Pelham House, West Sussex
AI-generated concerns summaryThe coroner identified an absence of signage on the A322 warning drivers of a pedestrian crossing point, recommending consideration for introducing such signage.
Addressed to: Surrey County Council
AI-generated concerns summaryGPs did not fully appreciate their role in managing high-risk allergies, including advising on two adrenaline auto-injector pens, dose adjustment, and device training. The CCG provided inaccurate guidance to prescribers regarding auto-injector scriptswitches.
Addressed to: Advanced Health & Care Ltd; Association of Ambulance Chief Executives; Bausch & Lomb UK Ltd; Department of Health & Social Care; Enfield Clinical Commissioning Group; London Ambulance Service NHS Trust; London Central & West Unscheduled Care Collaborative; Medicines & Healthcare Products Regulatory Agency; National Institute for Health & Care Excellence; NHS Digital; NHS England & NHS Improvement; Winchmore Hill Practice
AI-generated concerns summaryThe coroner noted the absence of professional lifeguard cover on Cornish beaches, particularly on a Bank Holiday Monday, and the lack of a clear public plan for its reinstatement. This situation increases the risk of further loss of life.
Addressed to: Department for Transport; Maritime and Coastguard Agency; Royal National Lifeboat Institute
AI-generated concerns summaryThe coroner noted the absence of professional lifeguard cover on Cornish beaches, including on Bank Holiday Monday when incidents occurred, and highlighted a lack of a public plan for reinstating these services.
Addressed to: Department for Transport; Maritime and Coastguard Agency; Royal National Lifeboat Institute
AI-generated concerns summaryNottinghamshire County Council's dementia care team does not routinely assess for deprivation of liberty (DoL) in community settings, and social workers are not trained to consider this issue. This raises concerns that individuals with significant liberty restrictions in their homes may be unlawfully deprived of liberty without adequate safeguards.
Addressed to: Nottinghamshire County Council
AI-generated concerns summaryThe coroner identified inadequate monitoring and supervision of repeat medication, leading to patients receiving dangerous quantities and widespread waste of healthcare resources.
Addressed to: NHS England
AI-generated concerns summaryThe coroner's concerns are encompassed within the jury’s determination attached to the report.
Addressed to: Department for Work and Pensions; London Ambulance Service NHS Trust; Metropolitan Police
AI-generated concerns summaryThe coroner noted that a safeguarding concern regarding Ms Smith-Cox's accommodation and living conditions was raised, but the support stakeholder did not receive or act upon it prior to her death.
Addressed to: Cornwall Council; Devon and Cornwall Police Adult Safeguarding Team; Pluss Work Choice
AI-generated concerns summaryThe coroner noted a lack of medical team review despite referral and conflicting views on responsibility between medical and ITU teams. There was a significant delay in obtaining a neurological opinion, which hindered early diagnosis, and issues with the standard neurology referral system.
Addressed to: Bedford Hospital NHS Trust
AI-generated concerns summaryThe deceased's family was not informed about his deteriorating condition or transfer to the Home Treatment Team, despite his request for their involvement. The trust's process for keeping families informed requires review.
Addressed to: Central Northwest London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns that the design of the filter lane and junction from the A1088 to Thetford Road does not prevent drivers from turning right ahead of bollards and onto the wrong side.
Addressed to: Transport and Rural Affairs at Suffolk County Council
AI-generated concerns summaryConcerns included the lack of Trust-maintained training records for individual nurses and the absence of a formal written care plan for a child with complex medical needs during a 15-month hospital stay.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the multi-step process for passengers to alert staff and for staff to activate the emergency brake. There is a reliance on members of the public to identify hazards on the track and activate alarms, as the central CCTV system cannot monitor all stations simultaneously.
Addressed to: Office of Rail & Road; Train Services, DLR; Transport for London
AI-generated concerns summaryThe coroner noted that had the GP been informed of the boy’s deterioration earlier, hospital admission with a real prospect of successful treatment could have occurred. Additionally, there was a dispute between ambulance crew and parents about hospital choice.
Addressed to: Lewisham Council; Lewisham & Greenwich NHS Trust; London Ambulance Service NHS Trust; Sydenham Green Group General Practice
AI-generated concerns summaryA department's refusal to investigate or accept its mistakes prevents learning and may risk future deaths.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryThe coroner noted a lack of a clear pathway for investigating dysphagia caused by a stricture, which meant a biopsy for potential malignancy was not undertaken. Additionally, fluid balance charts were inadequately completed, leading to a significant fluid overload not being identified until close to death.
Addressed to: East Kent University Hospital NHS Trust; NHS England NHS Improvements
AI-generated concerns summaryThe coroner raised concerns that newly qualified midwives may be permitted to work in the community without sufficient experience, noting this issue is not exclusive to one trust.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted poor documentation and a lack of understanding regarding the patient's capacity and needs, leading to unsuitable ward placements and a misunderstanding of his catheter type. Concerns were also raised about uncoordinated care and unclear roles among agencies in the integrated care model.
Addressed to: Bolton Council; Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust (GMMH); Royal Bolton Hospital