Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted a lack of an integrated mental health counselling and detoxification service in Stockport, which would enable joint treatment for co-occurring alcohol dependency and anxiety.
Addressed to: Stockport Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted the absence of a defibrillator at Marshalls Arts College, identifying this as a concern.
Addressed to: Leeds Martial Arts College
AI-generated concerns summaryThe NHS 111 service used medical terminology unclear to young patients and rigid scripts. Concerns were also raised about delays in GP uploading of triage notes and the lack of routine lipase/amylase testing for young people with abdominal symptoms.
Addressed to: NHS England; NHS Pathways; N.I.C.E; Roundwood Medical Centre
AI-generated concerns summaryGaps in guidance for communicating with non-verbal patients, along with substantial periods of missing entries and incomplete patient records, posed risks to patient care and inter-staff communication.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted inadequate checks of school allergy plans and medication, including expired EpiPens, and a lack of standardised action plans between hospitals and schools. Insufficient national guidance and training on immediate adrenaline administration was also identified.
Addressed to: British Society for Allergy and Clinical Immunology; Department for Education; Department of Health and Social Care; London Ambulance Service; London North West University Healthcare NHS Trust; Mylan Pharmaceuticals; Royal College of Paediatrics and Child Health; William Perkin High School
AI-generated concerns summaryMental health assessors should account for how a mental disorder manifests, such as the diurnal nature of reactive depressive illness, and document if an assessment during a good mood may not be valid for periods of low mood.
Addressed to: Cheshire and Wirral NHS Trust
AI-generated concerns summaryThe coroner noted unclear clinical leadership and communication within the maternity unit, alongside insufficient staffing levels, poor CTG interpretation, and inadequate record keeping.
Addressed to: Cwm Taf University Health Board
AI-generated concerns summaryThe coroner noted ongoing issues with untimely referrals for community nursing services for discharged patients. There was also a significant reliance on agency nurses within the Trust, impacting continuity of care and finances.
Addressed to: Tameside and Glossop Care NHS Trust; Tameside General Hospital
AI-generated concerns summaryStents of varying sizes are supplied in identical packaging, which increases the risk of the wrong size being used during medical procedures due to difficult identification. The coroner recommends purchasing agencies ensure manufacturers use distinct coloured packaging for different stent sizes.
Addressed to: Medicines and Healthcare products Regulatory Agency; NHS Improvement
AI-generated concerns summarySpecific concerns were unavailable as the text referenced an attached sheet.
Addressed to: Portsmouth Hospitals NHS Trust; Probation Service; SCAS; Southern Health NHS Trust
AI-generated concerns summaryThe coroner raised concerns about paramedic awareness and training regarding the dangers of administering blood-thinning medication, such as Rivaroxaban, to elderly patients with head injuries after a fall, emphasising that such injuries may not be immediately obvious.
Addressed to: Welsh Ambulance Service
AI-generated concerns summaryThe coroner noted insufficient mental health disclosure on UCAS applications and to prospective universities, alongside the absence of formal investigation reports by universities following student deaths to identify lessons learned.
Addressed to: Bristol University; Department for Education
AI-generated concerns summaryThe discharge documentation from the clinical decision-making unit was not standardised, leading to a lack of clarity and record of follow-up advice given to patients.
Addressed to: Worcestershire Acute Hospital NHS Trust
AI-generated concerns summaryThe coroner noted insufficient information provided to the psychiatric liaison practitioner regarding Mr. Jukes' arrest, including suicide threats, affecting her assessment. Concerns were also raised about a communication breakdown regarding his known status to mental health services, and that no psychiatrist visited him in custody.
Addressed to: Birmingham and Solihull Clinical Commissioning Group; Birmingham and Solihull Mental Health NHS Trust; Black Country Partnership NHS Foundation Trust; NHS England; West Midlands Police
AI-generated concerns summaryThe coroner noted that patients with cardiac event symptoms, not yet in cardiac arrest, may wait up to 40 minutes for a category 2 ambulance due to national response times. A local triage system designed to address this is not consistently applied due to resource limitations.
Addressed to: AACE - The Association of Ambulance Chief Executives; National Ambulance Service
AI-generated concerns summaryThe coroner identified issues with the police's paper-based Person Escort Record (PER) system, including officers lacking access to previous self-harm risk data from other agencies. Concerns were also raised about Detention Officer training and deficiencies in the PER's completion, checking, and secure handover processes.
Addressed to: Central & North West London NHS NHS Trust; GEOAmey; Hampshire Police Constabulary; HMP Winchester; MOJ
AI-generated concerns summaryGaps were identified in G4S healthcare professionals' access to individuals' full mental health background when assessing detainees in police custody, particularly outside of Liaison and Diversion Service (LADS) hours. This limited their ability to make informed decisions regarding further healthcare input, such as formal mental health assessments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner notes concerns regarding the poor quality, illegibility, and storage of clinical records within the Trust. These issues compromise the effectiveness of incident reviews and the quality of patient care during handovers, a matter previously raised.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted staff misunderstood or misapplied mental health risk assessment training, and important information was not consistently communicated between staff and other care providers.
Addressed to: East London NHS Trust
AI-generated concerns summaryPolice officers were unaware of the exact location of life lines on Brighton seafront, which caused a delay in deploying one. The coroner also noted the need for increased public awareness regarding the dangers of entering the sea under the influence of alcohol or drugs.
Addressed to: Sussex Police