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 Beechdale Medical Group lacked safe procedures for patient triage, home visit allocation, and documentation of patient calls and home visit notes. Concerns were also raised about insufficient clinical capacity and the absence of a process to review significant events for learning.
Addressed to: Beechdale Medical Group
AI-generated concerns summaryThe coroner noted a lack of opportunity for family to provide information to mental health teams, an unclear interplay between providers, and the absence of a patient roadmap to guide access to treatment.
Addressed to: West London Mental Health Trust
AI-generated concerns summaryThe consultant's advice to the GP regarding the continuation of certain pain medications was unclear, and the GP did not seek further guidance. The patient did not receive tailored written advice on his pain relief regimen or the risks of combining multiple opioid medications.
Addressed to: Bart’s Health NHS Trust; Rochdale Borough Housing Limited
AI-generated concerns summaryThe coroner raised concerns about seizure call scripting, specifically regarding how fitting duration is determined for call upgrades and the immediate prioritisation for patients not maintaining airways. Insufficient pathways for updating prison healthcare on call changes and for dialogue between hospital emergency departments and WAST on call categorisation were also …
Addressed to: Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted a lack of clear pathways for district general hospital radiologists to obtain direct specialist neuroradiological opinions, leading to inappropriate referrals. Suboptimal communication between the hospitals further delayed accurate diagnosis due to unclear questions, incomplete information, and slow image transfer.
Addressed to: Calderdale and Huddersfield NHS Trust; Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified that delays in transfer and surgery, caused by a surge in referrals and limited capacity, led to surgery being performed during SIRS, which increased the risk of death. There are concerns this risk will recur without the provision of more beds.
Addressed to: Department of Health and Social Care; Guys & St Thomas NHS Trust; NHS England
AI-generated concerns summaryConcerns were raised about the sufficiency of Approved Premises places and difficulties in recruiting and retaining probation officers. The coroner also noted the need to strengthen domestic violence arrangements, including statutory MARACs, with details on actions taken often absent.
Addressed to: Department of Health and Social Care; HM Prison & Probation Service; MOJ
AI-generated concerns summaryThe coroner raised concerns about the use of hard shoulders as running lanes on smart motorways, noting drivers do not expect stationary vehicles and that high speeds and limited escape options on certain stretches pose risks.
Addressed to: National Highways
AI-generated concerns summaryThe coroner noted two collisions at the Dover Road and Buckingham Avenue junction where turning vehicles struck cyclists. Concerns were raised that the current cycle lane design may position cyclists where they are not seen by turning drivers, increasing collision risk.
Addressed to: Slough Borough Council Highways Department
AI-generated concerns summaryConcerns were raised about a lack of information sharing between hospital departments, an absence of clear post-operative plans for extubation and ECMO, and a poorly executed clinical handover. These issues contributed to a delay in commencing ECMO therapy.
Addressed to: Great Ormond Street Hospital NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding the delayed recognition of Mr Gonzalez Barron's collapse, the absence of a dedicated welfare monitor, and inadequate briefing for the first aider on venue procedures and emergency protocols. There were also issues with clear communication for ambulance access and coordination at the scene.
Addressed to: First Aid Cover Limited; Roundhouse; White Branch Live Limited
AI-generated concerns summaryThe coroner noted risks from vehicles stopping in live motorway lanes, highlighting the lack of automatic detection for lone stationary vehicles. Concerns were raised about specific dangers on dynamic hard shoulder sections due to large gaps in emergency refuge areas and limited safe retreat for occupants.
Addressed to: Highways England
AI-generated concerns summaryAn ambulance was incorrectly dispatched to the wrong address, sending it to Mr Bean's father in Nottingham instead of Mr Bean in Cornwall.
Addressed to: East Midlands Ambulance Service
AI-generated concerns summaryThe coroner noted continuing concern regarding the volume and speed of traffic on the B5017 between Needwood and Burton, particularly at its various junctions. A further review of this stretch of road was suggested to improve its safety.
Addressed to: County Highways Department; Staffordshire County Council
AI-generated concerns summaryThe coroner noted inadequate discharge advice for Mr. Hodge following surgery, which failed to detail warning signs like breathlessness and persistent pain. There was also no patient information leaflet available for this type of procedure.
Addressed to: University Hospital Lewisham
AI-generated concerns summaryThe coroner noted concerns regarding the concurrent prescribing of clonazepam with methadone. This combination can cause central nervous system and respiratory depression, increasing the risk of sudden death, particularly given clonazepam's long half-life.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of updated care plans to reflect changing needs and multi-disciplinary decisions. Concerns were also raised regarding insufficient appropriate equipment, limited access to specialist advice, and inadequate staff training for equipment use and moving/handling.
Addressed to: Antron Manor Care Home
AI-generated concerns summaryConcerns were raised regarding the adequacy and effectiveness of allergen training for restaurant staff, particularly with high turnover, and the insufficient prominence of allergen notices on menus. Additionally, menus lacked explicit key allergen information, potentially leading to false reassurance for customers.
Addressed to: British Society for Allergy and Clinical Immunology; Byron Hamburgers; Department of Environment, Food and Rural Affairs; Department of Health and Social Care; Food Standards Agency; National Trading Standards Board
AI-generated concerns summaryThe coroner noted a lack of clear guidance and training for staff regarding residents with seizure risks bathing unsupervised, and insufficient reporting of incidents like hoarding, medication non-compliance, and absconding to relevant professionals and bodies.
Addressed to: Pentree Lodge Home
AI-generated concerns summaryThe coroner identified an inconsistent understanding among nursing staff about when to escalate to the critical care outreach team, as well as limited powers for outreach nurses to order urgent diagnostics. Inaccurate NEWS score recording was also noted, and the Trust's investigation failed to detect these issues.
Addressed to: Bedford Hospital NHS Trust