Browse 6,458 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 incomplete post-fall reviews, a lack of clear guidance from doctors on the frequency and duration of neurological observations after a fall, and issues with the proper follow-up of Nerve Centre system escalations.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryThe coroner expressed concern that emergency responders lack access details for vulnerable patients when assisting the ambulance service via the NHS "Access to the Stack" initiative, which could lead to future deaths.
Addressed to: Careline365; Norfolk Swift Response
AI-generated concerns summaryThe coroner noted that benefit entitlement was incorrectly determined due to errors not picked up by the checking process. Additionally, a standard letter was sent to a vulnerable individual despite known vulnerabilities, without mitigating the risk the letter might cause.
Addressed to: Department for Work and Pensions
AI-generated concerns summaryThe coroner identified a gap in apixaban patient information leaflets, which do not expressly advise on steps to take following head trauma. This absence of specific guidance may lead to delays in seeking medical advice, particularly for patients on anticoagulants, contrary to NICE guidelines for head injuries.
Addressed to: Association of the British Pharmaceutical Industry; Medicines and Healthcare Products Regulatory Agency; Medicines UK
AI-generated concerns summaryThe specialist National Early Warning Score matrix for prenatal women was not used throughout the hospital, and there were no immediate plans to implement it despite its intended use across all hospital departments.
Addressed to: NHS England; Royal Stoke University Hospital
AI-generated concerns summaryThe coroner noted staff confusion regarding the precise timing of 15-minute observations, with some believing a 15-30 minute range was acceptable despite a new policy. There is no national standard for these observation checks.
Addressed to: Black Country Healthcare NHS Foundation; FBC Manby Bowdler Solicitors
AI-generated concerns summaryThe coroner identified gaps in communication within the paediatric cardiology team and with other hospitals, noting a lack of early planning systems for diagnosing long QT in at-risk newborns. Concerns were also raised about the potential for drug selection errors due to drop-down menu prescribing.
Addressed to: Chelsea and Westminster Hospital; Great Ormond Street Hospital
AI-generated concerns summaryThe coroner noted reliance on mental health crisis patients waiting in open reception areas and a lack of suitable waiting facilities. This issue is compounded by a shortage of mental health beds, leading to prolonged waits.
Addressed to: Essex University Partnership Trust; NHS England
AI-generated concerns summaryThe coroner identified gaps in the Trust's investigation, specifically regarding the impact of bed unavailability, the decision to discharge without s17 leave, and the basis for capacity assessment. Concerns were also raised that ward rounds do not routinely facilitate private disclosure of family risk information.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryStaff discharging a patient to the Home Treatment Team were unaware of relevant policies, leading to inadequate risk assessments and safety plans. There was also an absence of guidance on managing potential conflicts of interest when staff recognise a patient outside of formal personal relationships.
Addressed to: Mental Health Directorate
AI-generated concerns summaryThe coroner noted a lack of liaison between prison medical services and community psychiatric services for patients with ongoing psychiatric issues at the time of release from custody, especially when prisoners are released far from their home address, which impacts continuity of care.
Addressed to: HM Prison & Probation Service
AI-generated concerns summaryNursing staff showed a lack of understanding on calling the Emergency Medical Response Team (EMRT) for patients with a Do Not Attempt Resuscitation (DNAR) order. There was also no risk assessment for Speech and Language Therapy (SALT) assessments for patients at risk of dysphagia.
Addressed to: Leigh Day and Co Solicitors; Sandwell and Birmingham Hospital NHS Trust
AI-generated concerns summaryThe coroner expressed concerns about the lack of regulation, registration, and training for doulas, noting that the diffuse nature of their role and absence of guidance on interaction with midwifery services can pose challenges and influence outcomes.
Addressed to: Department of Health and Social Care; NICE; Nursing and Midwifery Council
AI-generated concerns summaryThe coroner identified potential issues with poor record keeping and raised concerns regarding the level of compliance with care plans within the care home.
Addressed to: Care Quality Commission; Mulberry Court Care Home
AI-generated concerns summaryThe coroner identified that staff sometimes prioritised process over patient-centred care, noted a lack of clear clinical decision-making in rapid response referrals, and raised concerns about insufficient inclusion of receiving teams in discharge planning.
Addressed to: Kent and Medway NHS Mental Health Trust
AI-generated concerns summaryThe coroner raised concerns regarding the apparent absence or non-use of an upper alarm setting on bedside oxygen meters, which risks over-oxygenation. There was also a lack of clarity on whether such an alarm can be set or if it is standard practice.
Addressed to: Shewsbury and Telford Hospital Trust
AI-generated concerns summaryThe GamStop self-exclusion scheme does not cover unlicenced overseas gambling sites, meaning at-risk individuals are not protected. There is also insufficient public health information and warnings about the risks posed by these unregulated sites.
Addressed to: Department for Digital Culture, Media and Sport; Department for Education; Department of Health and Social Care; Gambling Commission
AI-generated concerns summaryThe coroner noted a lack of coordinated, real-time escalation and ownership of risk across multiple services for Mr Taylor. Clinical decision-making relied on his denial of intent despite significant risk indicators, and urgent referrals and family information were not actioned immediately.
Addressed to: Kent and Medway Mental Health Trust; Vita health Group : Kent and Medway Talking Therapies
AI-generated concerns summaryThe coroner raises concerns about extreme pressure on the London Ambulance Service, leading to missed response targets for patients and insufficient capacity to make welfare calls. This reflects a wider issue of demand outstripping capacity in ambulance services.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe care home lacked blood sugar monitoring for a Type 2 Diabetic resident due to unclear responsibilities between staff and community nurses. There were also no formal shift handovers, leading to incomplete information transfer and delayed escalation of a deteriorating condition.
Addressed to: Bank Close House Residential Care Home