Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryPost-operative instructions for urinary catheter management were unclear, and a disconnected epidural went unchecked for hours, delaying pain control and leading to pneumonia. Additionally, there was no routine post-operative follow-up by the operative consultant.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted confusion among emergency responders regarding call handler instructions, which appeared inconsistent with the primary duty to preserve life. Clearer guidance and training for call handlers are needed to ensure effective responses in hanging incidents.
Addressed to: College of Policing; South Wales Police
AI-generated concerns summaryThe coroner identified concerns about healthcare staff being advised not to make statutory Rule 35(2) reports, instead relying on ACDT procedures. Additionally, there was no formal process to inform the Home Office when a detainee was placed on ACDT.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified long waiting times for urgent psychotherapy, noting a 24-week wait exceeding the 18-week target due to insufficient funding and staffing. Concerns were raised that an 18-week target is too long for urgent mental health needs, potentially leading to further deaths while patients await treatment.
Addressed to: Department of Health and Social Care; NHS Tameside and Glossop Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified gaps in the operation of the Cornwall dual diagnosis policy, particularly concerning the interface and working relationship between Addaction and CMHT. Concerns were also noted regarding the development and implementation of their service level agreement delivery plan.
Addressed to: Cornwall NHS Trust; Drug, Alcohol Action Team Cornwall Council; NHS Kernow
AI-generated concerns summaryThe coroner raised concerns regarding the insufficient number of inpatient mental health beds in Birmingham and Solihull, resulting in patients requiring immediate admission not receiving treatment. The considerable distance of out-of-area beds also presented a particular difficulty for elderly patients and their families.
Addressed to: Birmingham and Solihull Clinical Commissioning Group; NHS England
AI-generated concerns summaryAn incomplete action plan from a root cause analysis, risks from a maternity service merger, and a culture of not performing specific procedures at night were noted. Additional concerns included insufficient staffing levels and leadership gaps.
Addressed to: Cwm taf University Health Board
AI-generated concerns summaryThe coroner noted that the 'triangle of care approach', where mental health team practitioners seek patient permission to approach family, is not consistently applied.
Addressed to: 2gether NHS Trust
AI-generated concerns summaryThe coroner noted the discontinuation of the Care Program Approach upon prison transfer, inadequate psychological support and record-keeping, and limited quality of documentation and attendance at multi-disciplinary care plan meetings.
Addressed to: Greater Manchester Mental Health & Social Care Trust; HM Prisons and Probation Service
AI-generated concerns summaryThe coroner identified issues with the clarity of information sharing forms, the RIO system's functionality in displaying and populating data, and a lack of 'no response' and 'welfare check' policies for primary care services. Concerns also related to staff training on these systems and procedures.
Addressed to: Avon and Wilshire Mental Health NHS Trust
AI-generated concerns summaryFurther steps are necessary to improve the management of illicit substance misuse within the prison, including the installation of CCTV on all wings and airport-style scanners. Extending the current Governor's appointment would allow more work to be undertaken to enhance inmate safety.
Addressed to: G4S; HM Prisons and Probation Service; MOJ
AI-generated concerns summaryThe coroner identified issues with medication information sharing between clinical and discipline staff, inadequate opiate and alcohol withdrawal protocols, and a lack of formal audits on medication administration. There were also concerns about the adequacy of staff training.
Addressed to: Chief Inspector of Prisons; Care Quality Commission; MOJ; Police and Prisons Ombudsman
AI-generated concerns summaryThe coroner identified poor communication between County Hospital and Royal Stoke University Hospital regarding patient transfer. There were also difficulties in securing a gastroenterology bed at Royal Stoke for the patient.
Addressed to: University of North Midlands Hospital NHS Trust
AI-generated concerns summaryInsufficient adherence to the Trust's EWS policy led to inadequate monitoring and delayed medical reviews for Mr. Flynn despite his clinical deterioration. The coroner also noted a lack of consultant review and an unavailable ICU outreach team.
Addressed to: Tameside General Hospital
AI-generated concerns summaryThe coroner noted fundamental flaws in the Trust's original investigation into a patient's fall and a need for revised investigation training. There were also concerns about the lack of guidance for frontline staff on capturing evidence immediately after falls.
Addressed to: Stockport NHS Trust
AI-generated concerns summaryThe coroner noted insufficient discussion with the deceased regarding investigatory options, attributing this to the absence of a clear system for obtaining informed consent. Concerns remain about the lack of outpatient contact for patient and family discussions prior to admission for procedures.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe provided text is incomplete and does not detail any specific concerns regarding future deaths.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner noted concerns regarding insufficient doctor staffing, as only one doctor was on duty for multiple responsibilities, and the practice lacked resources to undertake a home visit even if indicated.
Addressed to: Highlands and Trafalgar Square Surgery
AI-generated concerns summaryThe coroner noted the CCG only commissioned services for autism diagnosis, not management, resulting in a lack of local in-patient provision for individuals requiring mental health treatment. This leads to out-of-area placements, which is contrary to guidance on local provision.
Addressed to: East Leicestershire and Rutland Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that residents were regularly unsupervised in communal care home areas, creating a risk of resident-on-resident incidents leading to trauma. Information on risk management and supervision arrangements was absent.
Addressed to: Reinbek Care Home