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 noted the absence of national guidelines for referring patients with known valve disease from primary to secondary care, or secondary to tertiary care.
Addressed to: British Cardiovascular Intervention Society; Department of Health and Social Care; National Institute for Health and Care Excellence; NHS England; NHS Improvement
AI-generated concerns summaryThe coroner identified that the discharging consultant did not understand his role in capacity assessments or the inappropriateness of the patient's transfer. Guidance for inter-unit transfers remained incomplete years after the death.
Addressed to: Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of documented policy for District Nurse referrals to Tissue Viability Nurses, leading to unrecorded patient information. Concerns included TVN staff shortages and insufficient adherence to anaemia management guidelines.
Addressed to: Northern Care Alliance; Oldham Clinical Commissioning Group; Royal College of Nursing; Royal College of Pathologists
AI-generated concerns summaryDelays in ambulance response for a C2 call and a lack of re-assessment for a deteriorating patient after multiple calls were noted. The coroner also raised concerns about inconsistencies in triage algorithms, clinical input referrals, and health advisor training.
Addressed to: North East Ambulance Service
AI-generated concerns summaryThe coroner noted a lack of a dedicated Case Manager for Mr. Kirsch's ACCT document, leading to inadequate completion of the Caremap. This resulted in significant concerning behaviours and issues not being recorded or addressed within the ACCT process.
Addressed to: HMP Long Lartin
AI-generated concerns summaryThe coroner identified concerns regarding unnecessary and inappropriate patient transfers between hospitals, noting that the Trust's transfer policy was effectively ignored. Additionally, previous Regulation 28 reports concerning the transfer policy had not led to changes, and new assessment tools were not used.
Addressed to: Brighton and Sussex University Hospital NHS Trust
AI-generated concerns summaryTransfers between CHRTT and ATS do not consistently involve appointing a lead practitioner, potentially delaying patient treatment and monitoring.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding the untimely administration of Beriplex, a lack of follow-up to ensure it had been given despite an extended bleed, and a lack of clarity regarding its non-administration and the patient's location.
Addressed to: Norfolk and Norwich University Hospital
AI-generated concerns summaryCommunication of prisoners required for court the next day was not immediately apparent to night staff, preventing the identification of increased self-harm risk for those prisoners.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryGateway assessors lacked full access to patient notes, which could result in assessments and treatment plans being based on incomplete information.
Addressed to: ABMU Health Board
AI-generated concerns summaryNuffield's discharge policy is lengthy, generic, and lacks clear definition of roles and responsibilities for staff or guidance for arranging post-discharge investigations. There was insufficient evidence that implemented changes had improved the quality or accuracy of discharge communications.
Addressed to: Nuffield Health
AI-generated concerns summaryGateway assessors did not have full access to patient notes, which could lead to incomplete assessments and treatment plans based on insufficient information.
Addressed to: ABMU Health Board
AI-generated concerns summaryThe coroner identified potential neurological damage from chemoradiotherapy provided in a clinical trial and highlighted the need to investigate the mechanism of this injury, whether direct or through the immune system.
Addressed to: University of Birmingham
AI-generated concerns summaryThe coroner identified that Mrs Jarvis did not receive a proper medical examination by a doctor during her final psychiatric admission. The report notes a need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.
Addressed to: Midland Partnership NHS Trust
AI-generated concerns summaryThe coroner raised concerns that serious injuries, including fractures and head injuries, sustained by the deceased in a road traffic collision were overlooked during her attendance at Lister Hospital.
Addressed to: East and North Hertfordshire NHS Trust
AI-generated concerns summaryConcerns were identified regarding the potential for e-cigarette heating coils in prison to be misused for drug preparation and to start fires. The coroner questioned if e-cigarettes for prison use could be manufactured with sealed heating components.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted a lack of communication between hospital departments regarding patient responsibility, leading to the patient being without fluids for over 24 hours. Additionally, there was no senior clinician review for 24 hours and a lack of policy for nursing staff to proactively manage her condition.
Addressed to: University Hospital of North Midalnds
AI-generated concerns summaryThe coroner identifies a lack of national awareness and consistent management for Acute Behavioural Disturbance (ABD). Concerns include the absence of joint national guidance and adequate training for Police and Ambulance Services, plus differing terminology between emergency services.
Addressed to: Association of Ambulance Chief Executives; St John Ambulance; College of Policing; Department of Health and Social Care; Dorset Police; National Ambulance Service Medical Directors; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner noted differential treatment for detainees on the substance misuse unit, specifically a lack of dedicated night-time prison officers. Concerns were also raised that this at-risk population did not receive the same level of care as detainees on formal ACCT plans.
Addressed to: HMP Wormwood Scrubs
AI-generated concerns summaryThe coroner believes Ford should consider fault code provision when the DMF protection system leads to engine shutdown. Ford is also requested to forensically examine the vehicle to identify relevant faults.
Addressed to: Ford UK; Highways England