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 need for clinical record-led handovers focusing on risk, verbal communication of increased suicidal risk, timely and prioritised alternative placements for high-risk patients, and inter-unit sharing of complex cases.
Addressed to: NHS East Leicestershire and Rutland CGC; NHS England; Springfield Hospital
AI-generated concerns summaryThe coroner noted a lack of protocol for observing and assessing locum staff in practice, potentially leading to them working beyond their capabilities. There was also a reluctance at a managerial level to supplement locum references with telephone calls.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryPrison staff did not have ready access to current training records, specifically for ACCT and SASH, leading to officers working with outdated or absent training in safer custody processes.
Addressed to: HMPPS
AI-generated concerns summaryThe coroner noted the absence of established links between police Safeguarding and NHS mental health teams, impacting officers' ability to access professional advice for referrals. The report also highlighted a need for further mental health training for officers and a single point of contact for non-urgent advice.
Addressed to: Metropolitan Police service; South London and Maudsley NHS Foundation
AI-generated concerns summaryThe report identifies a lack of a systematic process for recording patient weights and notes that a consultant did not identify risks of GI bleeding or refer to a specialist despite concerning clinical indicators.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe document used for daily call bell checks is pre-populated with 'P' for pass, which risks rooms being missed or failures not being accurately recorded, potentially affecting patient safety.
Addressed to: Crown Care
AI-generated concerns summaryThe coroner noted concerns regarding the absence of a documented rationale for downgrading an urgent GP mental health referral without consulting the patient or GP. Additionally, the staff member making the triage decision was not identified, and no system for accountability in such decisions was in place at the time …
Addressed to: Goodmayes Hospital Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding 999 call handling for domestic abuse, the initial lack of policy explicitly linking perpetrator suicide risk to victim risk, and not supplying a replacement phone to a victim whose device was seized for evidence.
Addressed to: College of Policing; Crime, Policing and Fire Service; National Police Chief’s Council
AI-generated concerns summaryThe coroner noted concerns from Mr Turner's family regarding his anxiety about potential delays in accessing mental health services and the impact of missing a call from them on his ability to receive support.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that a hazardous task proceeded without formal risk assessment or method statement, and an ineffective permissioning system permitted an untrained worker to operate a safety boat. There was also no safe platform for known debris removal.
Addressed to: JV Ltd; Nuttall Ltd
AI-generated concerns summaryInsufficient gynae-oncology consultant cover at Newham University Hospital hindered patient advocacy and oversight. The coroner also noted the absence of a system for timely consultant reviews, and that previously agreed actions to address these issues had not been completed.
Addressed to: Barts NHS Trust
AI-generated concerns summaryThe coroner noted conflicting guidance for clinicians on monitoring Vitamin D and Calcium blood levels, with no advice issued to the GP for community monitoring. There were also concerns about WellSky and EMIS software allowing prescribing of doses exceeding national guidelines due to confusing dropdown menus.
Addressed to: EMIS; Royal Bolton Hospital; Wellsky
AI-generated concerns summaryThe coroner raised concerns about A&E consultants' knowledge of sepsis in babies, inadequate understanding of sepsis risk stratification tools, and inconsistent use of sepsis terminology. The report also noted failures to consider alternative antibiotic administration methods.
Addressed to: Cardiff and Vale University Health Board
AI-generated concerns summaryThe coroner noted that emergency department crowding is associated with increased mortality among admitted patients, with approximately 500 deaths per year attributed to overcrowded emergency departments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe WGH maternity unit has insufficient capacity to provide safe patient care. Guidance for consultants restricts caesarean section availability by including a 'not as first choice' caveat, even after failed induction, without reference to clinical considerations.
Addressed to: Watford General Hospital
AI-generated concerns summaryThe lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Addressed to: Sussex Police
AI-generated concerns summaryThe coroner notes the absence of national NICE guidance for Acute Behavioural Disturbance (ABD). Experts believe such guidance would prevent future deaths and provide practical support for medical professionals, police, and other responders.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe SystmOne computer system hinders prison healthcare staff from effectively accessing prisoners' mental health histories for risk assessments due to poor search functionality and unreliable 'Summary' and 'Active Problems' sections. This limits the identification of suicide risk, relying instead on a prisoner's immediate presentation.
Addressed to: Central and North West London NHS Foundation Trust; Government legal department; HM Prison; NHS
AI-generated concerns summaryThe quick-reference 'Do's and Don'ts' section on co-sleeping in the Trust's Red Book omits the advice against co-sleeping with premature or low birth weight babies. While the full advice is elsewhere, the immediate impact information should be complete and accurate.
Addressed to: Staffordshire, Shropshire and Black Country New born and Maternity Network
AI-generated concerns summaryThe coroner noted the nurse in charge's lack of training and experience in dealing with a patient's collapse, including poor emergency response and inadequate knowledge of specialist equipment and CPR procedures.
Addressed to: Select Healthcare