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 that discharge letters were sent only to the GP, not all medical attendants, leading to a lack of information for original prescribers regarding stopped medications. This could impact comprehensive patient care.
Addressed to: Department of Health and Social Care; NHS England; NHS Improvement
AI-generated concerns summaryAngel Solutions (UK) Ltd provided inadequate personal care regarding hygiene, repositioning, and pressure sore management, with insufficient staffing and poor record-keeping. The coroner is concerned about the company's continued care provision and risk of future inadequate care.
Addressed to: Angel Solutions (UK) Limited
AI-generated concerns summaryGaps were identified in police officer training for Emergency Life Support, recognising agonal breaths, and managing restraint risks. Other concerns included the clarity of the safety officer role in street settings and noise levels in the communication centre.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner noted that emergency call handlers did not prompt callers reporting a person in the river to request coastguard assistance or provide location references from signage, potentially delaying the arrival of appropriate assets.
Addressed to: 999 Liaison Committee; Department for Culture, Media and Sport; London Ambulance Service
AI-generated concerns summaryThe coroner identifies deficiencies in ACCT plans from the absence of a single case manager, affecting care and follow-up. Concerns were also raised about a disparity between evidence and inspection findings on implementing single case management at HMP Birmingham.
Addressed to: HMP Birmingham, MOJ, G45
AI-generated concerns summaryThe coroner noted staff lacked dedicated time for regular policy refreshers after initial training. Additionally, inconsistent medication policies across care homes regarding when to call a GP for refused doses could cause confusion, especially for transferring staff.
Addressed to: Crystal Care Limited; Sapphire House
AI-generated concerns summaryThe coroner raised concerns regarding the extensive availability of self-harm and suicide-related content online for young people, noting that this material risks normalising such actions and goes beyond appropriate freedom of expression.
Addressed to: Department for Digital, Culture, Media & Sport
AI-generated concerns summaryThe coroner noted ineffective attempts by the Local Authority and police to manage car cruising, highlighting the failure of a Public Spaces Protection Order due to enforcement issues. A multi-agency, adequately funded, and pan-Greater Manchester approach is needed to prevent future incidents.
Addressed to: Greater Manchester Combined Authority; Home Office
AI-generated concerns summaryThe coroner identified a lack of integrated care and insufficient information sharing among multiple health agencies, which prevented a comprehensive care plan or coordinated oversight of the child's needs post-discharge.
Addressed to: Department of Health and Social Care; Greater Manchester Combined Authority
AI-generated concerns summaryThe coroner notes that Strongyloides stercoralis forms are not routinely screened for prior to transplant surgery, despite the infection being treatable if identified early and prevalent worldwide.
Addressed to: British Transplantation Society; NHS Blood and Transplant
AI-generated concerns summaryThe coroner identified a potential shortage of suitable placements for individuals with mental health history, leading to persistent difficulties for social workers and occupational therapists in finding appropriate facilities.
Addressed to: Cornwall Council
AI-generated concerns summaryIneffective shift handovers meant staff were unaware of a patient's recent fall and the need for increased observations, a gap compounded by insufficient management checks. There were significant delays in seeking medical advice for a deteriorating patient, and vital information was not adequately provided to the GP or paramedics.
Addressed to: National Institute for Health and Care Excellence; Shaw Healthcare
AI-generated concerns summaryThe coroner noted inadequate consideration and action for a crucial public sighting report of Mr Sykes, leading to an insufficient police search of the identified sports fields by only two officers. Increased deployment could have led to an earlier discovery.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner noted that Newham University Hospital's system allows clinical streamers to decide patient destination based on an initial check and brief history, before full clinical observations are taken. A safer process would ensure observations are available to the streamer before seeing the patient.
Addressed to: Barts Health NHS Trust; Newham Co-operative; Royal Docks Medical Practice
AI-generated concerns summaryThe coroner noted that critical information regarding a patient's potential septicaemia, identified by NHS 111, was not adequately transferred to ambulance crews and GPs. Additionally, medical professionals are only notified of ambulance delays exceeding 40 minutes, potentially impacting timely treatment for rapidly deteriorating conditions.
Addressed to: Association of Ambulance; East of England Ambulance Service; N.I.C.E
AI-generated concerns summaryThe coroner identified insufficient follow-up in sharing information with the National Probation Service regarding a patient's association with a high-risk individual, which limited the Probation Service's opportunity to consider further safeguards.
Addressed to: National Probation Service; RDaSH NHS Trust
AI-generated concerns summaryThe coroner identified that employees at Beatson Clark are regularly and extensively exposed to polycyclic aromatic hydrocarbons without protective equipment, which is linked to Urothelial Tract Carcinoma. This continued exposure presents a risk of future deaths.
Addressed to: Beatson Clark
AI-generated concerns summaryThe coroner raised concerns regarding NHS Pathways for 111 call handlers, noting inadequate questions for recognising acutely unwell children, issues with pain assessment, and the absence of a failsafe mechanism for escalating repeated calls about a child's health.
Addressed to: NHS Digital; NHS England
AI-generated concerns summaryThe coroner noted inefficient and archaic neurosurgical referral processes at UHW, handled by a single on-call registrar, leading to delays and miscommunication. Additionally, there is no back-up doctor available for time-critical referrals.
Addressed to: Cardiff and Vale University Health Board; Cwm Taf Morgannwg University Health Board; Hwyel Dda University Health Board; Powys Teaching Health Board; Swansea Bay University Health Board; Welsh Assembly Government
AI-generated concerns summaryThe coroner identified a lack of communication between Turning Point and the GP regarding Ms Shaw's significant butane gas use. Additionally, only recent medical records were transferred between substance misuse service providers, limiting access to a full patient history.
Addressed to: Hopwood House Medical Practice; NHS Oldham Clinical Commissioning Group; Turning Point