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 a previous lack of a structured mobility scale to assess patients' well-being and identify health decline during hospital stays. A new mobility scale is now being introduced at Royal United Hospital to improve this assessment.
Addressed to: NHS Improvements
AI-generated concerns summaryThe GP practice's computer system incorrectly classified repeat prescriptions, hindering medication reviews, and clinical notes lacked sufficient detail. A lack of continuity of care led to repeated painkiller prescriptions without exploring alternative treatments, and a large tramadol prescription was issued without clear rationale.
Addressed to: Delamere Medical Practice
AI-generated concerns summaryThe coroner is concerned that medical devices are being used in non-emergency procedures outside manufacturer's instructions, which increases the risk of device failure and the need for high-risk emergency open surgery.
Addressed to: Royal London Hospital
Addressed to: Care UK; HMP Pentonville; National Offender Management Service
AI-generated concerns summaryThe coroner identifies a difference between national JRCALC guidance and local ambulance Trust guidance on calculating the 15-minute timeframe for resuscitation, creating potential for misinterpretation and risk of future deaths.
Addressed to: Joint Royal Colleges Ambulance Liaison Committee
AI-generated concerns summaryGood Hope Hospital's practices were not consistent with national guidelines, and junior staff did not identify or escalate a patient's deterioration due to insufficient senior staffing over a Bank Holiday weekend. Concerns were also raised regarding a lack of integrated protocols across all Trust sites.
Addressed to: University Hospitals Birmingham NHS Trust
AI-generated concerns summaryThe coroner identified issues with the oversight of duty worker decisions, the management of waiting lists, and the process for patient non-attendance at the hospital. Concerns were also raised about the inclusion of family in care planning and the lack of a system for identifying service boundaries to ensure correct …
Addressed to: Coventry & Warwickshire Partnership Trust; Coventry NHS Trust
AI-generated concerns summaryThe coroner identified a lack of joint handovers between drug detoxification and primary care nurses, alongside unclear responsibilities for observations and animosity between these teams. Concerns were also raised about the absence of a clear protocol for examining injection sites and DVT sites.
Addressed to: Birmingham Community Healthcare NHS Trust
AI-generated concerns summaryInsufficient information sharing between ambulance and police services included a misspelled name that hindered police intelligence and unclear communication regarding the purpose of police attendance. There is no agreed protocol for such welfare checks.
Addressed to: Emergency Operation Centre Norwich; Melbourne Ambulance Station
AI-generated concerns summaryThe coroner identified concerns regarding an apparent breakdown in communication for emergency admissions, noting that despite pre-alert calls, hospital clinicians appeared unprepared and specialist teams were not forewarned of the patient's arrival.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding ambulance technicians administering anticoagulation medication (Apixaban) to Mrs Millward Winter after a head injury. This administration worsened an internal bleed and contributed to her death.
Addressed to: Each Step Nursing Home; NORTH WEST AMBULANCE SERVICE
AI-generated concerns summaryThe coroner noted insufficient staff knowledge and training in falls management and neuro observations, leading to inadequate monitoring and delayed medical assistance for a patient with a suspected head injury. Risks were also identified for medically unwell mental health patients due to poor training and the inability to implement the …
Addressed to: Cardiff & Vale University Health Board; Nursing & Midwifery Council
AI-generated concerns summaryThe coroner noted that the average time to transfer prisoners to a secure hospital under s.47 of the Mental Health Act 1983 significantly exceeds the 14-day recommendation, often taking months. This prolonged delay presents a risk of further deaths.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted a surprising discharge from hospital after an overdose without a psychiatric liaison assessment, poor history-taking at UHW, and insufficient GP medication reviews contributing to an overdose risk.
Addressed to: Cardiff and Vale University Health Board; West Quay Surgery
AI-generated concerns summaryThe NHS Pathways algorithm lacks a question regarding recent surgical procedures for patients reporting severe abdominal pain. There is also insufficient emphasis on speaking directly with the patient when a non-patient makes the NHS 111 call.
Addressed to: NHS Digital
AI-generated concerns summaryThe coroner identified a need for specific training for Prison Custody Officers explaining deportation documentation and raised concerns about foreign national prisoners lacking access to a duty lawyer scheme for immigration advice. Further review is required for the safety design of first-floor mezzanine railings at HMP Altcourse.
Addressed to: Home Office; MOJ
AI-generated concerns summaryThe coroner noted delays or absence of discharge summaries from the Isle of Wight NHS Trust to GPs, affecting continuity of care for mental health patients. Concerns were also raised about insufficient out-of-hours mental health staff due to funding limitations.
Addressed to: St Mary’s Hospital NHS Trust
AI-generated concerns summaryThe coroner raises concerns about the lack of a safe pedestrian crossing on the A3054 at a point frequented by elderly residents with mobility issues. The existing crossing is inaccessible due to a steep incline, increasing pedestrian risk on the busy road.
Addressed to: Island Roads; Isle of Wight Council
AI-generated concerns summaryA national campaign is needed to address the inherent risks of rapid alcohol consumption, how to identify at-risk persons, the importance of timely medical intervention, and risks associated with initiation events.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted false assertions by staff regarding patient observations and GP calls, a failure to record vital observations, and that the care home's records were inaccurate and misleading.
Addressed to: Brancaster Care