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 challenges in assessing unwell children remotely via 111 and Out of Hours services, proposing mandatory annual staff training on paediatric symptoms, access to specialist clinicians, and advising ambulance calls if uncertain.
Addressed to: Herts Urgent care Limited; NHS 111; NHS Digital; Public Health England
AI-generated concerns summaryThe coroner identified inconsistent patient record-keeping, errors in NEWS chart completion, and missed observations. Concerns were also raised regarding an ad hoc system for ECG requests and the absence of a policy for managing opiate-dependent patients.
Addressed to: Cwm Taf Morgannwg University Health Board
AI-generated concerns summaryThe coroner noted concerns regarding a vulnerable patient's transfer to a ward where fundamental nursing care was later found deficient, and the C-diff investigation process did not extend to prior wards where care failings occurred.
Addressed to: St Thomas NHS Foundation Trust
AI-generated concerns summaryMrs. Barrow received Diazepam prescriptions without confirmation from mental health services or adequate GP checks regarding illicit access to the medicine. The practice also had not recently reviewed its approach to prescribing Diazepam.
Addressed to: Heaton Moor Medical Group
AI-generated concerns summaryThe Home Treatment Team lacks a dedicated Consultant Psychiatrist, and recruitment plans for this role are unclear. Interim arrangements for accessing psychiatric support are inconsistently effective and depend on individual psychiatrists' availability.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryConcerns were raised about residents having unrestricted access to clinical examination gloves and their disposal in easily accessible bins in care settings. Authoritative guidance on the storage and disposal of such gloves is recommended.
Addressed to: MHPRA
AI-generated concerns summaryThe coroner noted gaps in communication between midwifery and social worker teams, exacerbated by staff shortages, impacting fetal monitoring. Concerns also included undocumented triage calls, unrecorded decision-making, and delayed identification of sepsis.
Addressed to: HSIB; The Secretary of State for Health
AI-generated concerns summaryThe SystmOne computer system used for medication prescription and review at HMP Warren Hill was described as unclear and difficult, hindering GPs from verifying current prescriptions, tracking medication adherence, and managing prisoner medications effectively.
Addressed to: NHS England; SystemOne TPP Ltd
AI-generated concerns summaryThe coroner noted that the external maintenance staircase was easily accessible to the public and lacked a lockable gate, despite not requiring regular public access.
Addressed to: Stamford Quarter Shopping Centre
AI-generated concerns summaryThe coroner noted insufficient involvement of healthcare staff in the ACDT process, inconsistent checks for medication swallowing, and a lack of clinical information sharing between Hillingdon Hospital and Colnbrook IRC following an overdose.
Addressed to: CNWL NHS Trust; Hillingdon Hospital NHS Trust; Home Office; Langley Health Centre; Mitie
AI-generated concerns summaryThe British National Formulary (BNF), a resource regularly consulted by GPs, does not appear to include advice for caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, unlike other pharmacological guidance.
Addressed to: N.I.C.E
AI-generated concerns summaryThe coroner noted high pressure on resources and the failure to conduct a required two-hour review to assess if the matter needed recategorization, identifying this as a risk in future cases.
Addressed to: Yorkshire Ambulance Service
AI-generated concerns summaryThe coroner noted gaps in legal requirements for vehicle rental companies to report suspicious hirers or share intelligence, and the lack of a system to prevent individuals of interest from hiring vehicles. Concerns were also raised regarding the absence of sufficient protective barriers at London Bridge, despite prior recommendations.
Addressed to: Department for Transport; Metropolitan Police Service; British Vehicle Rental and Leasing Association; City of London Police; Home Office; London Ambulance Service; National Counter Terrorism Security Office; Secret Intelligence Service; Security Service
AI-generated concerns summaryConcerns involved an 11-week delay in Tyla being seen by the Eating Disorder Service and the absence of up-to-date written care and crisis plans. Additionally, a recommended multi-disciplinary learning event for emergency response had not been organised, with responsibility for it remaining unclear.
Addressed to: Norfolk and Suffolk NHS Trust; Norfolk County Council; Queen Elizabeth Hospital; West Norfolk Clinical Commissioning Group
AI-generated concerns summaryThe improvement plan presented did not address specific service shortcomings, and there is no dedicated channel for external healthcare professionals to urgently discuss patient clinical needs with ambulance staff to inform response urgency.
Addressed to: Welsh Ambulance Service
AI-generated concerns summaryA critically unwell child was placed in the Accident and Emergency waiting area without visual assessment by staff, delaying discovery of her condition. This missed the opportunity to apply Royal College of Emergency Medicine guidance for early assessment and escalation of care.
Addressed to: Calderdale and Huddersfield NHS Trust; Chief Coroner
AI-generated concerns summaryThe coroner raised concerns that other public authorities may not proactively address safety issues without a fatal incident, requesting national learning following a tragic avoidable death.
Addressed to: Department of Housing, Communities & Local Government; Local Government Association
AI-generated concerns summaryThe coroner raised concerns regarding the legibility of painted road markings and the existing road layout, noting potential for motorist confusion.
Addressed to: Calderdale Council
AI-generated concerns summaryThe coroner noted delays and a lack of key information during Mr Dundhal's Mental Health Act assessment, contributing to an incomplete clinical picture and his placement on an incorrect section. Concerns were also raised about the failure of Walsall MBC to investigate these issues.
Addressed to: Birmingham City Council; Birmingham Women’s and Children’s NHS Trust; Priory Group of Hospitals; Walsall MBC
AI-generated concerns summaryThe coroner noted the early discharge of a child following a prolonged seizure and the Luton & Dunstable NHS Trust's absence of prescriptive clinical guidelines for such cases, including the failure to consider neuroprotective strategies.
Addressed to: Luton & Dunstable NHS Trust