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 inadequate communication between the Hospital and occupational therapist, leading to delays in implementing an appropriate exercise regime. There was also insufficient urgency among professionals to resolve the matter quickly, potentially increasing the risk of complications.
Addressed to: New Cross Hospital NHS Trust; Wolverhampton City Council
AI-generated concerns summaryThe coroner noted that the NICE Guidance for the Diagnosis and Management of Allergy was not followed on 2nd September 2017.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a lack of specific advice for safe alcohol reduction for individuals attempting it independently, and that patients may not be aware of all urgent symptoms of alcohol withdrawal besides seizures.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner raised concerns that an untrained paramedic was instructed by a hospital doctor via telephone to reduce a suspected hernia, a procedure beyond their role and potentially dangerous if strangulated. There was also concern about staff feeling pressured to avoid hospital admissions.
Addressed to: East Kent University Hospitals; NHS England; South East Coast Ambulance Service
AI-generated concerns summaryThe coroner raises concerns that the proposed requirement for individuals with Borderline Personality Disorder to agree to a transfer to an Integrated Delivery Team may prevent some patients from accessing new in-house treatment, given the nature of BPD and past treatment experiences.
Addressed to: Norfolk & Suffolk NHS Trust
AI-generated concerns summaryThe coroner noted insufficient monitoring of plastic cutlery on the ward, which was used for self-harm, and inadequate searching processes for patients returning from unescorted leave, allowing self-harm materials to be brought in. Concerns were also raised about significant variations in the conduct and recording of hourly observations.
Addressed to: Oxford Health NHS Trust
AI-generated concerns summaryMr Brown's care records were not reviewed before his assessment, which meant his full history and risks were not considered. This recurrent issue with the Trust was not addressed in their subsequent investigation.
Addressed to: Norfolk & Suffolk NHS Trust
AI-generated concerns summaryTraining does not sufficiently emphasise the heightened risks of prone restraint when multiple factors affect breathing. There are also concerns that officers' training prioritises speedy removal of a restrained person rather than an opportunity to assess their condition once control is obtained.
Addressed to: Association of Police Officers; College of Policing; Sussex Police
AI-generated concerns summaryRoseberry Care Centres did not adequately prioritise dental hygiene or dental service provision for residents, which potentially worsened a dental abscess. There were also insufficient policies for managing missed dental appointments and identifying when appointments were required.
Addressed to: Roseberry Care Centres
AI-generated concerns summaryNorthumbria Police did not formally communicate the discontinuation of an investigation to the employer and Local Safeguarding Adults Board. This prevented the employer from updating their employee on her employment status and the Safeguarding Board from progressing its review.
Addressed to: Northumbria Police
AI-generated concerns summaryThe coroner raised concerns regarding the lack of consultation between mental health and physical health doctors, and the failure to provide suitable and adequate care for the patient's needs at the Centre.
Addressed to: Oxleas NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the adequacy of road markings, as only broken white lines were present where a collision occurred. An expert believed that double solid white lines, prohibiting overtaking, could have prevented the incident.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner identified concerns regarding the junction's configuration and positioning, the adequacy of street lighting, vegetation affecting visibility, and the appropriateness of the speed limit at the scene.
Addressed to: Cheshire West and Chester Council
AI-generated concerns summaryThe coroner notes a lack of suitable long-term housing and rehabilitation placements for young mental health patients in RBKC, and highlights the need for improved discharge planning and consideration of rehabilitation before discharge.
Addressed to: Central and North West London NHS Trust; Royal Borough of Kensington and Chelsea
AI-generated concerns summaryThe coroner noted breakdowns in the information chain concerning a D-Dimer test request and results, which were not available to the discharging doctor. Concerns were also raised regarding system failures to record test requests, alert clinicians to outstanding tests, and secure access for agency staff.
Addressed to: Shrewsbury and Telford NHS Trust
AI-generated concerns summaryConcerns include an unmarked bus stop on a 50mph road with no safe standing area or pedestrian crossing facilities. Additionally, vegetation obstructs pedestrians, and there is unclear responsibility for its management.
Addressed to: Kent County Council; Regent Coaches in Whitstable, Kent
AI-generated concerns summaryThe coroner noted the absence of a system for staff to alert and track individuals exhibiting unusual behaviour via CCTV, and no alarms at platform end barriers. It was recommended that station staff procedures for monitoring ticket barriers and CCTV ease of use be reviewed.
Addressed to: Transport for London
AI-generated concerns summaryThe Thames Valley Transfer Network Checklist does not require oxygen supply checks or a tug test when transferring oxygen to a portable cylinder, which could lead to unnoticed failures in oxygen flow.
Addressed to: Thames Valley and Wessex Operational Delivery Networks
AI-generated concerns summaryThe care home failed to implement specific care plans to address Mr. Brooker's high risk of falling, despite multiple incidents. Concerns also included insufficient reporting of falls to commissioning authorities and a lack of referrals for professional mobility assessments.
Addressed to: HC-One
AI-generated concerns summaryThe current NHS Pathways system does not enable ambulance call handlers to recognise Excited Delirium/Acute Behavioural Disturbance, pending an update. Concerns were also raised regarding potentially confusing interim guidance for call handlers and the content of clinical staff training on this condition.
Addressed to: College of Policing; Joint Royal Colleges Ambulance Liaison Committee; Mitie; NHS England; South East Coast Ambulance Service Service; Surrey Police; Teesside University Hospitals