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 raised concerns about the adequacy of staffing levels and staff training at the care home on specific dates when the deceased fell, questioning compliance with Regulation 18 of the Health and Social Care Act 2008.
Addressed to: Glenholme Holdingham Grange Care Home
Addressed to: TUI UK & Ireland, Wigmore House, Wigmore Place, Wigmore, Luton, Bedforshire, LU2 9TN
AI-generated concerns summaryThe coroner noted concerns that the initial ambulance call, where an individual was threatening self-harm, was inappropriately coded as Category 3 instead of Category 2. This coding error contributed to a significant delay in the emergency response, which may have altered the outcome.
Addressed to: Association of Ambulance Chief Executives; Emergency Call Prioritisation Advisory Group (ECPAG); National Association of Ambulance Medical Directors
AI-generated concerns summaryThe coroner identified ward staffing shortages, insufficient medical documentation, and a lack of a clear system for regular orthogeriatric consultant reviews to escalate deterioration. The trust also did not follow its own falls risk policy.
Addressed to: Department of Health and Social Care; Manchester University Foundation Trust (MFT)
AI-generated concerns summaryThe coroner noted improper clinical waste disposal, where previous instances were not escalated. A resident's behaviour of ingesting non-food items was also not adequately documented or risk-assessed, leading to an insufficient care plan.
Addressed to: Care Quality Commission (CQC); Department of State for Social Care
AI-generated concerns summaryThe report identifies a lack of an Integrated Treatment System in Wales. The coroner raised concerns about the inequality in healthcare provision, as Welsh prisons do not automatically offer opiate substitution therapy to new opiate-addicted arrivals, unlike English prisons.
Addressed to: Department of Health and Social Care; Minister for Health; Welsh Assembly
AI-generated concerns summaryThe coroner noted inadequate assessment and management of self-harm risk in prison, particularly a failure to update a prisoner's risk profile after significant changes and to communicate this altered risk to the receiving wing.
Addressed to: National Offender Management
AI-generated concerns summaryThe coroner identified a lack of reliable and consistent methods for sharing medical records and information between two NHS trusts, alongside an absence of formalised joint decision-making processes for complex patient care involving both trusts.
Addressed to: Pennine Care NHS Foundation Trust; Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies a lack of mandatory comprehensive training for Firearms Enquiry Officers (FEOs) and deficiencies in the medical fitness assessment system for shotgun certificate applicants, particularly regarding unclear guidance on relevant conditions and insufficient GP input.
Addressed to: British Medical Association; Department of Health and Social Care; Surrey Police; Home Office; National Police Chief’s Council
AI-generated concerns summaryThe coroner identified an absence of mandatory comprehensive national training for Firearms Enquiry Officers. Concerns were also raised regarding the system for assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate guidance on what medical conditions applicants must declare.
Addressed to: British Medical Association; Department of Health and Social Care; Surrey Police; Home Office; National Police Chief’s Council
AI-generated concerns summaryThe coroner noted that some psychiatrists ask GPs to instigate Lithium prescriptions, contravening the shared care protocol. This practice leads to delays or non-provision of essential medication for mentally ill patients.
Addressed to: Greater Manchester Medicines Management Group; NHS Stockport Clinical Commission Group
AI-generated concerns summaryThe coroner raised concerns regarding inadequate fluid management, which led to patient dehydration and incomplete input/output charting. There were also insufficient clinical observations and no protocol for their frequency on the ward.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner identified poor physical care of vulnerable patients on Summers Ward, noting insufficient communication between doctors and nurses. Concerns included inaccurate recording of clinical observations and a lack of awareness regarding mandatory oxygen administration training.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe inquest determined that a hip fracture sustained in hospital, which ultimately necessitated a girdlestone procedure, likely contributed to the individual's death.
Addressed to: Lynmere Nursing home
AI-generated concerns summaryThe coroner raised concerns about the safety of a pedestrian crossing area near a school, noting insufficient warnings for drivers, a lack of street lighting, and the absence of specific measures such as dedicated crossings or school crossing patrols to protect pedestrians.
Addressed to: Lincolnshire County Council Highways Department
AI-generated concerns summaryThe coroner noted inconsistent and incomplete guidance documents regarding the safe stacking, unstacking, and loading of bales in agriculture. This lack of definitive instruction creates a risk of unsafe practices leading to future fatalities.
Addressed to: Department for Transport; Health and Safety Executive
AI-generated concerns summaryThe GP practice lacked a clear system for alert notes and follow-up reviews for patients on extensive prescribed medication. Additionally, there was no system to ensure prescribers were aware of high alcohol use to assess medication interaction risks.
Addressed to: Greater Manchester Health and Social Care Partnership; Tameside and Glossop Clinical Commissioning Group
AI-generated concerns summaryThe coroner raised concerns regarding the HSIB's conduct, noting they asked the Trust not to investigate, which delayed recognition of issues and immediate remedial action. The HSIB investigation was lengthy (18 months), and its final report contained factual errors and was insufficiently detailed.
Addressed to: Department of Health and Social Care; East Surrey Hospital; HSIB; NHS England
AI-generated concerns summaryThe coroner identified a lack of a robust system to ensure regular assessment of patients who decline contact or care from healthcare providers but continue to receive repeat prescriptions.
Addressed to: GP Surgery Parkway Health Centre
AI-generated concerns summaryThe mental health trust and GP practice did not follow NICE guideline CG90, which requires a 1-week follow-up for patients under 30 or with increased suicide risk when starting antidepressants, to monitor for side effects including suicide risk.
Addressed to: Avon and Wiltshire NHS Mental Health Trust; Department of Health and Social Care; Minister of Suicide Prevention; Student Health Service