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 summaryConcerns were raised about the lack of systems to monitor and assist patients dependent on finite oxygen supplies, and the absence of formal procedures for recording oxygen expiry times. Additionally, training in oxygen administration remains incomplete.
Addressed to: Cwm Taf University Health Board
AI-generated concerns summaryThe coroner raised concerns regarding the absence of an adequate falls assessment policy and a clear escalation pathway after a patient experienced sequential falls, noting that each incident was dealt with reactively without proactive risk reduction.
Addressed to: Borough Care Limited
AI-generated concerns summaryThe coroner noted that signs prohibiting swimming at Shadwell Basin are too small and easily missed. The signs should be larger, more prominent, and clearly state the specific dangers of swimming, such as poor visibility, undercurrents, and submerged debris.
Addressed to: London Borough of Tower Hamlets
AI-generated concerns summaryThe coroner raises concerns that the elevated risk of self-harm and suicide among remand prisoners is not adequately incorporated into staff training, highlighted to care teams, or reflected in national guidance and risk assessment documents.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner raises concerns about the lack of awareness among medical professionals, carers, and families regarding the fire risk posed by petrol-based emollient creams, which can impregnate clothing and cause rapid fire spread.
Addressed to: British Medical Association; Care Quality Commission; Department of Health and Social Care; National Institute for Health and Care Excellence; Public Health England; Trent and Dove Social Housing
AI-generated concerns summaryConcerns included the Probation Service's unclear policy for referring at-risk individuals to medical services, along with the supported accommodation's poor documentation, inconsistent handover, and insufficient staff training on welfare checks and risk assessments.
Addressed to: HM Prison and Probation Service; Jigsaw Homes Group
AI-generated concerns summaryConcerns were raised regarding C&I ward staff's lack of understanding about police procedures for missing patients, including necessary information for escalation. This was coupled with delays in police classification of the patient as high-risk and incomplete information for police decision-makers.
Addressed to: Camden & Islington NHS Trust; Metropolitan Police Service
AI-generated concerns summaryThe coroner identified an inexperienced police officer handling the investigation, which led to delayed evidence seizure and insufficient focus on the child's voice. There were also gaps in information sharing between agencies and reliance on agency social workers by the Local Authority.
Addressed to: College of Policing; Department for Education; Department of Health and Social Care
AI-generated concerns summaryThe coroner questioned whether a recommendation for CAT Team Leaders to contact NHS 111 regarding unassessed Category 3 calls, especially for attempted suicides, had been implemented. Concerns were also raised about EMAS's inability to escalate Category 3 calls to Category 2 when their target response time was exceeded.
Addressed to: CAT; East Midlands Ambulance Service
AI-generated concerns summaryThe coroner raised concerns about the lack of visible signage on station platforms warning commuters of the live 'third rail' electrocution risk, especially in high-footfall areas. The report also noted the absence of tactile paving or crosshatch markings near the platform edge.
Addressed to: South Western Railways; Office of Rail and Road
AI-generated concerns summaryThe coroner noted expert evidence identifying a risk of children deteriorating unnoticed when adult and child patients are mixed in urgent care centres.
Addressed to: Bromley Clinical Commissioning Group; Greenbrook Healthcare
AI-generated concerns summaryThe coroner noted deficiencies in the Trust's Root Cause Analysis process, particularly the lack of psychiatric expertise and scrutiny, and raised concerns about clinicians not appropriately applying the Mental Health Act regarding 'de-facto' detention.
Addressed to: Midlands Partnership NHS Trust
AI-generated concerns summaryThe coroner identified inadequate and remotely inaccessible electronic patient records, insufficient information sharing with the GP about delayed antibiotic treatment, and a failure to complete sepsis pathway checks. Additionally, a scheduled patient visit was incorrectly missed.
Addressed to: Medway Community Healthcare
AI-generated concerns summaryThe coroner identified the absence of a single database for prescription-only medication, which hinders clinicians from identifying previous prescriptions. Concerns also include online prescribers avoiding CQC regulation and new pharmaceutical guidance being advisory rather than mandatory.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns that GP-led alcohol detoxification programs may lack adequate specialised support for patients with dependency history, requiring follow-up appointments beyond the medication course. Additionally, a computer system issue meant a complete list of recent prescriptions was not always readily accessible to practitioners.
Addressed to: Village Medical Centre
AI-generated concerns summaryThe coroner noted the care providers' reliance on applicant information without routinely seeking independent medical details from GPs, resulting in an unsuitable resident being admitted. A full service user assessment, care plan, and risk assessments were also not completed.
Addressed to: Friendship Care and Housing Limited
AI-generated concerns summaryThe paramedic did not consider meningitis or use the Sepsis Tool, which would have indicated the need for hospital conveyance. Additionally, communication with the family about the necessity of hospital admission was insufficient, leading to a misunderstanding.
Addressed to: West Midlands Ambulance Service
AI-generated concerns summaryThe coroner noted a lack of clear guidance for care home staff regarding safe sleeping positions for vulnerable adults, increasing the risk of unsafe sleeping for those unable to reposition themselves.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted gaps in formal systems at Spire Bristol for managing unexpected patient reattendances post-discharge, including processes for assessment, immediate consultant notification, and comprehensive record keeping.
Addressed to: Spire Bristol Hospital
AI-generated concerns summaryDisjointed management of a high-risk pregnancy resulted from the absence of identified consultants overseeing care. A serious adverse development went unheeded as the tertiary centre lacked awareness of the baby's inactivity prior to the planned C-section.
Addressed to: Hull University Teaching Hospitals NHS Trust