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 identified an inadequate process for checking the patient’s warfarin level dosage, with the GP practice reportedly relying on the family to confirm the required amount rather than independently verifying it.
Addressed to: Brace Street Health Centre; Care Quality Commission
AI-generated concerns summaryThe coroner identified the absence of a multi-agency review for a high-risk offender after a serious incident. Concerns also include the impact of the Transforming Rehabilitation Programme on probation staffing and procedures, and difficulties with the N-Delius case management system.
Addressed to: Greater Manchester Police; Lancashire Constabulary; Ministry of Justice; National Police Chiefs’ Council; National Probation Service
AI-generated concerns summaryThe coroner noted that ambulances dispatched to Mr Davies' Category 3 overdose call were repeatedly diverted to higher priority patients during a period of high demand, leading to a delay in attendance.
Addressed to: NHS Digital; NHS England
AI-generated concerns summaryThe coroner raises concerns that probation hostel staff lack awareness and training regarding Acute Behavioural Disturbance (ABD), a potential medical emergency, which could impact appropriate management and information sharing.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner highlighted a lack of communication between mental health professionals and patients' relatives due to confidentiality, noting that relatives often hold valuable information which could aid care decisions.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryOngoing unavailability of an Approved Mental Health Practitioner caused delays in assessments. There was also a lack of communication between police and mental health services, missing an opportunity for re-engagement.
Addressed to: Birmingham and Solihull Mental Health NHS Trust; Birmingham City Council; West Midlands Police
AI-generated concerns summaryThe coroner raised concerns regarding the length of the post-procedure observation period following an episode of vomiting and the clarity of written discharge advice about seeking further medical attention for post-procedure vomiting.
Addressed to: University Hospital of North Midlands
AI-generated concerns summaryConcerns were raised regarding a lack of accessible lower-level mental health support for young people who do not meet CAMHS thresholds. There were also gaps in information sharing between the GP, CAMHS, and school, hindering a comprehensive understanding of the individual's needs.
Addressed to: Milton Keynes Clinical Commissioning Group; Public Health England
AI-generated concerns summaryThe coroner identified a misunderstanding between agencies concerning the urgent use of Section 135 Mental Health Act warrants, regarding notice periods and bed availability. The report notes insufficient inter-agency cooperation and learning from incidents.
Addressed to: Birmingham and Solihull Mental Health NHS Trust; Birmingham City Council; Department of Health and Social Care; NHS Birmingham and Solihull Clinical Commissioning Group; NHS England; West Midlands Police
AI-generated concerns summaryThe coroner asks the Department to review resource availability for Local Authorities with many young people in care and limited qualified staff, and to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services, and educational pastoral care.
Addressed to: Department for Education; Department of Health and Social Care
AI-generated concerns summaryThe London Ambulance Service did not communicate critical pregnancy information during a pre-hospital alert and upon hospital arrival, which led to a delay in the hospital's recognition of the pregnancy and calling the obstetric team.
Addressed to: London Ambulance Service NHS Trust; Whittington Health NHS Trust
AI-generated concerns summaryThe coroner identified gaps in the medical centre's inquiry and recording of a patient's illicit drug misuse, which prevented an informed risk assessment for prescribing pregabalin and oxycodone given potential interactions.
Addressed to: West Timperley Medical Centre
AI-generated concerns summaryThe coroner noted inadequate referral processes for the Tissue Viability Nurse, including the use of voicemails and a lack of follow-up on referrals. There was also insufficient and inconsistent record-keeping for the patient's wound, lacking detailed descriptions, measurements, and photographs.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner noted a delay in reviewing and updating safer swallowing training for staff, despite an earlier recommendation for completion by May 2019. The relevant training package had not been updated, and no new timeframe for completion could be provided.
Addressed to: University Hospitals Birmimgham NHS Trust
AI-generated concerns summaryThe coroner noted the absence of national guidelines or recommendations for preventing deep vein thrombosis and pulmonary embolism in patients undergoing upper limb surgery, despite clear guidelines existing for other contexts.
Addressed to: Department of Health and Social Care; North Middlesex University Hopsital
AI-generated concerns summaryThe coroner raised concerns for the Three Bridges Regional Operating Centre (ROC) about the discovery of a body by a member of the public at Preston Park Station.
Addressed to: Govia Thameslink Railways; Network Rail
AI-generated concerns summaryThe coroner noted that CQC inspections do not always require assessment of external areas of care homes, even when regularly used by residents. Consideration should be given to automatically including such areas as part of inspections.
Addressed to: Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner identified a lack of resources, treatment systems, and information sharing for individuals with serious mental illness and co-occurring alcohol or drug misuse. The Mental Health Act was also noted as outdated in addressing these complex needs and prioritising patient safety.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted that a call was incorrectly graded, and even if correct, insufficient West Midlands Police resources meant it and most other lower priority calls would not have been answered due to the volume of higher priority calls that night.
Addressed to: Home Office; West Midlands Police
AI-generated concerns summaryThe coroner noted that Johnnie Johnson Housing imposes no conditions on tenants regarding furniture fire safety standards and is not undertaking a formal review into introducing sprinkler systems into its properties.
Addressed to: Johnnie Johnson Housing