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 noted insufficient processes for managing controlled drugs in care and nursing homes, leading to difficulties in accounting for medication and inaccurate stock sheets.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner noted a lack of national guidance for managing pressure ulcer risks in Emergency Departments. This can result in inadequate Trust policies, particularly for vulnerable patients experiencing prolonged stays in the ED awaiting ward transfer.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner raised concerns about Fluoxetine accumulating to dangerous levels that could trigger cardiac rhythm disturbance, questioning if dosage guidance needs revision or in-life drug level testing. Additionally, the death was not reported via the Yellow Card system.
Addressed to: Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe coroner raised concerns about the Walsall Healthcare NHS Trust lacking a specific policy to prevent birthing mothers using a pool without appropriate foetal heart rate monitoring equipment. There were also issues with inadequate newborn resuscitation techniques and insufficient mandatory refresher training for midwives in newborn life support skills.
Addressed to: Walsall Healthcare NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the inadequacy and poor legibility of beach signage and information notices, noting the distance of the beach patrol officer from the incident. The report suggests more extensive surveillance and improved liaison with the RNLI.
Addressed to: Tendering District Council
AI-generated concerns summaryThe coroner raises concerns about repeated pedestrian fatalities at a specific location on Ringwood Road lacking a crossing near bus stops and a retail park, despite previous recommendations. The report also notes insufficient and non-functional street lighting, contributing to poor visibility.
Addressed to: Bournemouth, Christchurch and Poole Council; Department for Transport
AI-generated concerns summaryThe coroner noted insufficient adherence to and understanding of Scout Association safety policies at a local level, with a lack of proper risk assessments and effective leadership. Concerns also included inadequate organisational oversight and health and safety training without competency assessment.
Addressed to: Scout Association
AI-generated concerns summaryThe Priory's internal investigation did not critically analyse care against the care plan, indicating an inability to learn from serious incidents. There was also a lack of clarity on staff adherence to care plans and no formal review of Clozapine monitoring for patients.
Addressed to: Priory Group
AI-generated concerns summaryThe coroner identified a need to review the A5 junction with Streetway Road for potential safety improvements, including additional signage or modifications to the road layout.
Addressed to: Commissioner for Highways
AI-generated concerns summaryThe coroner noted the absence of a pedestrian crossing on the A12 near the collision site, expressing concern about the delay in implementing a traffic management order and the ongoing need for a dedicated crossing.
Addressed to: Tower Hamlets Council; Transport for London
AI-generated concerns summaryThe coroner raised concerns regarding inadequate public access control and ineffective warning signs at a dam, where exposed live wiring caused an electrocution. There was also a lack of explanation or report from authorities regarding the incident.
Addressed to: High Commissioner for Saint Lucia to the UK
AI-generated concerns summaryThe coroner raised concerns regarding the toxic effects of drugs when taken excessively with other medication, and that permitting patient "self-certification" without checks and not informing a GP removes safeguards for vulnerable individuals with addiction.
Addressed to: NHS England
AI-generated concerns summaryThe TTT service's repeated cancellations led to individuals being discharged without clinical assessment of their mental state. The procedure for re-engagement after cancellations is informal, lacks written policy, and inconsistent across staff areas.
Addressed to: Sussex Community NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a gap in the supervision and monitoring of patients who do not meet admission protocols between RAID and Home-Based Treatment Team (HBTT) services. This led to a practitioner experiencing difficulty in obtaining essential monitoring for a patient who fell between service remits.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryPoor street lighting at the junction of Lake Road and Upwey Avenue, where the middle of the wide junction is particularly poorly illuminated, poses a risk to pedestrians and other road users.
Addressed to: BCP Council
AI-generated concerns summaryThe coroner noted incomplete documentation for leave, the AWOL procedure not being followed, a lack of handover between Safety and Security workers, and insufficient training on policy and procedure. An appropriately sufficient action plan also remains outstanding.
Addressed to: Lancashire Care NHS Trust
AI-generated concerns summaryThe coroner noted significant delays in the diagnosis and treatment of Mr Smith's adenocarcinoma. Tests and appointments occurred consecutively rather than concurrently and expeditiously, preventing surgery from taking place.
Addressed to: SATH; UNMH
AI-generated concerns summaryThe coroner noted that the electronic transfer system limits information shared during patient handovers, potentially omitting critical details. National policy currently compounds this by only mandating electronic transfer information for transfers.
Addressed to: NHS England; University Hospital of Derby and Burton
AI-generated concerns summaryThe report raises concerns that insufficient resourcing for urgent patient transfers could lead to a risk of future deaths for acutely ill patients.
Addressed to: Chesterfield Royal Hospital; East Midlands Ambulance Service; Royal Derby Hospital
AI-generated concerns summaryThe coroner identified a communication error that confused ingestion with spillage and noted that an effective antidote for toxicity was not available on the ambulance.
Addressed to: West Midlands Ambulance Service