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 summaryConcerns were raised about ineffective communication during handovers, the non-application of NICE guidelines for head injury, and an assumption of patient intoxication that delayed the recognition of a significant head injury.
Addressed to: Royal United Hospital
AI-generated concerns summaryThe Royal United Hospital (RUH) paediatric ward lacks a second ward round for consultants to review patient status with fresh eyes. There is also no High Dependency Unit (HDU) facility on the paediatric ward for children requiring closer monitoring.
Addressed to: Banes Clinical Commissioning Group; Royal United Hospital, Bath
AI-generated concerns summaryThe coroner noted the possibility of pedestrian confusion due to a 'see-through' green signal at a two-stage crossing. A wider concern is that other similar crossings in England and Wales may lack features like louvres and road markings to prevent this and warn pedestrians of traffic direction.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted that a doctor who treated the deceased became untraceable after leaving the UK, preventing their account from being provided. This limited the completeness of the investigation and the doctor's ability to learn from the issues raised, impacting accountability.
Addressed to: Cwm Taf Health Board; General Medical Council
AI-generated concerns summaryThe coroner noted insufficient police awareness of victim notification after suspect bail and gaps in GPs' knowledge of disclosure duties. Concerns were also raised about the MARAC process being ineffective for chaotic individuals.
Addressed to: Department of Health and Social Care; Home Office; Local Government Association; London Borough of Lewisham; National Police Chiefs Council
AI-generated concerns summaryThe coroner identified concerns regarding the national speed limit and lack of street lighting on a section of the A590 in Backbarrow, affecting pedestrian safety near a primary school. Insufficient signage for an alternative underpass was also noted.
Addressed to: Highways England
AI-generated concerns summaryThe coroner noted insufficient systems for ensuring radiographers had seen and acknowledged standard operating procedures for CT scans, coupled with a lack of audit to confirm their training records were documented and current.
Addressed to: University Hospitals Birmingham NHS Trust
AI-generated concerns summaryThe coroner noted an ongoing and worsening shortage of radiology clinicians at Derriford Hospital, with a need for 16 additional staff, which may contribute to work pressures and future fatal errors.
Addressed to: Derriford Hospital; University Hospitals Plymouth NHS Trust
AI-generated concerns summaryThe coroner identified insufficient assessment of the deceased's impaired cognition and mental capacity regarding bath safety, inadequate information sharing with mental health teams, and a lack of urgent prioritisation for an apparent risk of death.
Addressed to: Manchester City Council; Manchester Mental Health NHS Trust
AI-generated concerns summaryPolice issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.
Addressed to: Greater Manchester Police; Home Office
AI-generated concerns summaryThe coroner noted that the reservoir fence was regularly damaged, allowing easy access. Concerns were also raised that signage warning of swimming risks did not consider the needs of people with learning disabilities.
Addressed to: Health and Safety Executive; Royal Society of Prevention of Accidents
AI-generated concerns summaryAn incorrect warfarin prescription, resulting from a mislabelled anti-coagulation chart, went unidentified by multiple medical professionals for several days and lacked ward-based pharmacy review. The Trust's proposed actions to address such prescribing errors are still in early stages of implementation.
Addressed to: Nottinghamshire University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that other windows within the building did not have any window restrictors in place, despite ambiguity about the specific window involved in the incident.
Addressed to: Crossing Project
AI-generated concerns summaryThe coroner identified gaps in ensuring regular blood tests for renal failure patients under specialist care, noting a lack of shared care arrangements and clear responsibility for monitoring. Communication of test results and updates to primary care was insufficient, relying solely on patients.
Addressed to: Northern Care Alliance NHS Group; Oldham Care Commissioning Group; Pennine Care NHS Trust; St Chads Medical Practice
AI-generated concerns summaryThe coroner noted the withdrawal of a falls service, which previously assisted individuals who had fallen at home. This withdrawal risks patients' lives and contributes to long waits for ambulance service response.
Addressed to: Milton Keynes Clinical Commissioning Group
AI-generated concerns summaryNo specific concerns text was provided for summarization.
Addressed to: NHS Pathways; South East Coast Ambulance Service
AI-generated concerns summaryThe recruitment process for a doctor with significant responsibility and access to anaesthetic drugs was inadequate, leading to concerns about the appointed doctor working alone and posing potential risks.
Addressed to: Central Medical Services
AI-generated concerns summaryConcerns included insufficient care provision, unaddressed falls risks and lack of equipment in the discharge plan for a stroke patient, alongside a failure to involve family or review the plan when care needs changed.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner identified difficulties during a medical evacuation due to the crew's unfamiliarity with a wheelchair extraction chair and its incompatibility with the vessel's crane and tender, which led to significant delays in transporting the injured person.
Addressed to: International Maritime Organisation; Vantage Drilling Company
AI-generated concerns summaryThe coroner noted the need for prisons to ensure appropriate equipment is available for barricade situations, especially for non-dual-opening cell doors. They also identified a need for an audit to confirm this equipment is correctly located within prisons.
Addressed to: MOJ