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 donor's CMV status was not communicated to the deceased for informed consent, nor was this critical information effectively shared with the renal transplant team, indicating a gap in their communication process.
Addressed to: Manchester University NHS Trust
AI-generated concerns summaryThe coroner noted a lack of provision for the ambulance service to utilise other emergency services for assistance or updates during significant delays when no personnel were on scene.
Addressed to: Cheshire Constabulary; Cheshire Fire and Rescue; Department of Health and Social Care; North West Ambulance
AI-generated concerns summaryThe coroner noted insufficient counselling regarding the risks of exceeding a prescribed medication dose, with warnings on the drug leaflet and bottle also deemed inadequate.
Addressed to: Boehringer Ingelheim Limited
AI-generated concerns summaryThe coroner identified a lack of formal carer's assessments and irregular contact from the case coordinator, leading to outdated care plans and risk assessments. Concerns were also raised about supervisory arrangements failing to detect these issues.
Addressed to: Cornwall Partnershipship NHS Trust
AI-generated concerns summaryThe report noted a lack of appropriate support and systems to encourage junior midwives and doctors to escalate concerns, and insufficient understanding of the need to retain placentas post-delivery.
Addressed to: Gloucestershire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted it was not routine for healthcare staff to attend ACCT reviews, which was a concern relating to both prison and healthcare operations despite improvements introduced after the death.
Addressed to: Care UK; Midlands Partnership NHS Foundation Trust; HM Prison and Probation Service; St Georges Hospital
AI-generated concerns summaryThe coroner noted the patient experienced a fall during hospital admission that resulted in a severe traumatic brain injury, leading to subsequent palliative care.
Addressed to: Medway Maritime Hospital
AI-generated concerns summaryA Crisis Line call taker did not ask a patient if he was feeling suicidal, despite knowing his recent history of intent to jump, which limited opportunities for intervention.
Addressed to: East London NHS Trust
AI-generated concerns summaryThe coroner is concerned about ensuring that recommendations from a multi-disciplinary investigation are consistently followed.
Addressed to: Derriford Hospital Trust
AI-generated concerns summaryThe coroner identified a lack of protection for a victim of domestic abuse when the perpetrator, though under police investigation, had no bail conditions or restrictions. The report requests a review of procedures and resources to protect victims and prevent future deaths.
Addressed to: Home Office
AI-generated concerns summaryThe coroner raised concerns regarding the prescription of Clozapine alongside numerous other medications, leading to significant weight gain and potential cardiovascular issues, and the lack of consideration for familial lipid disorders that might contraindicate its use.
Addressed to: Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner noted a lack of continuity in crisis team care, with numerous different individuals involved and no apparent contact from the Community Psychiatric Nurse before discharge. Concerns were also raised about the crisis team's capacity to support high-risk individuals due to significant pressures and low service user expectations.
Addressed to: Leicester NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding a medication error partly attributed to the Phosphate Polyfusor product design and staff not checking medication packaging against prescriptions. Insufficient guidance, documentation, and training were also identified for healthcare professionals on medication administration and transfer procedures.
Addressed to: Medicines and Healthcare products Regulatory Agency; Nursing and Midwifery Council; Salford Royal Hospital NHS Trust
AI-generated concerns summaryProfessionals lacked understanding of Pica's significant health risks, including bezoar development, and there is no national or professional guidance for Pica identification, management, or monitoring for bezoars.
Addressed to: British Psychological Society; Chief Medical Officer for England; National Autistic Society; Royal College of General Practitioners; Royal College of Paediatrics and Child Health; Royal College of Physicians; Royal College of Psychiatrists; Royal College of Speech and Language Therapists
AI-generated concerns summaryThe coroner identified matters giving rise to concern during the inquest, noting a risk that future deaths could occur unless action is taken.
Addressed to: NHS Pathways
AI-generated concerns summaryConcerns were raised about the slow investigation and incomplete follow-up by Boots regarding methadone tablet disparity, and the lack of robust audit checking for controlled drugs. Additionally, the General Pharmaceutical Council has no reporting requirements, investigative powers, or sanctions for pharmacies discovering Schedule 2 controlled drug discrepancies.
Addressed to: Boots UK Limted; GPC; NHS England
AI-generated concerns summaryThe coroner noted that daily staff shortages in the Emergency Department contributed to problems on 4th June 2019, raising concerns that this poses a risk to patients.
Addressed to: Milton Keynes University Hospital
AI-generated concerns summaryThe coroner identified that Hamerton Zoo lacks conventional firearms to address a tiger escape, and the process to obtain them is incomplete, with insufficient trained staff. Concerns were also raised about the lack of clear national guidelines requiring zoos to possess licensed conventional firearms.
Addressed to: Cambridgeshire Constabulary; Department for Environment, Food and Rural Affairs; Hamerton Zoological Park; Health and Safety Executive; Local Government Association; Sphere Risk Health & Safety Management Ltd
AI-generated concerns summaryThe coroner identified a lack of continuity in antenatal care, which could lead to missed abnormalities or risk factors, and insufficient direct provision of safe-sleeping information to new parents.
Addressed to: Midwifery and Maternity Portsmouth Hospitals NHS Trust; Portsmouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a delay in CPR commencement and identified that many prison officers lack basic life support training, particularly those employed when it was not mandatory, with no retrospective training provided.
Addressed to: MOJ