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 trust lacked an escalation process for rejected psychiatric referrals and had no agreed target timescales for routine appointments. Concerns were also raised about gaps in documenting referral rationales and insufficient information sharing between different mental health services within the same trust.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the absence of specific safety regulations for multi-purpose nursing pillows, which led to inconsistent warnings. The product's warning label was not attached, and some leaflet images could mislead parents about leaving babies unattended on the pillow.
Addressed to: Department for Business; Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns that current medical emergency policies may not cover all urgent situations requiring immediate hospital transfer, as an emergency medicine expert has not yet reviewed them to identify potential gaps.
Addressed to: Oxleas NHS Trust
AI-generated concerns summaryThe coroner identified insufficient follow-up of a high globulin finding in A&E, indicative of a fatal disease, due to issues with laboratory reporting and clinician alerts. Concerns were also raised regarding the clarity of cardiac monitoring instructions in drug prescribing information.
Addressed to: Amgen Limited; Kings College Hospital; Medicines and Healthcare products Regulatory Agency; The Royal College of Emergency Medicine; The Royal College of Pathologists; The Secretary of State for Health
AI-generated concerns summaryThe coroner noted a recognised long-term addiction to prescribed medication continued to be managed through repeat prescriptions, without referral for addiction support. This prescribing pattern allowed significant access to the medication.
Addressed to: Tameside and Glossop Clinical Commissioning Group
AI-generated concerns summaryThe hospital's Early Warning System was not adhered to, leading to missed opportunities for senior medical reviews. There was also inadequate record-keeping by clinicians, with doctor input following nursing escalation often not recorded and notes entered non-chronologically.
Addressed to: Department of Health and Social Care; Doncaster Bassetlaw Teaching Hospital
AI-generated concerns summaryThe coroner identified a lack of a mechanism to notify schools when pupils attempted to access blocked content related to self-harm on school computers. Concerns were also raised about whether enhanced monitoring functionality is mandatory for all schools.
Addressed to: Department for Education
AI-generated concerns summaryWelfare visits to retired priests in 'grace and favour' properties did not include health and safety or risk assessments, even when residents had a history of falls and mobility issues. This meant significant trip hazards, such as loose floor tiles, were not identified or addressed in the deceased's home.
Addressed to: East Coast Community Healthcare Team; Head of the Roman Catholic Church of England and Wales; The Diocese of Westminster
AI-generated concerns summaryThe report identifies gaps in the risk assessment for unescorted leave and the recording of family requests. Delays occurred in reporting a patient missing due to inaccurate departure times and the absence of a CCTV review policy.
Addressed to: Norfolk and Suffolk NHS Trust
AI-generated concerns summaryThe coroner noted multiple missed opportunities to identify the deceased as a high falls risk, to refer her to the falls team, and to provide falls prevention equipment. No falls risk assessments or care plans had been undertaken.
Addressed to: Beechwood Lodge Care Home
AI-generated concerns summaryThe coroner noted insufficient detail in discharge letters to GPs and KMPT's failure to adhere to its policy for post-discharge patient contact. Concerns were also raised about inadequate communication with patient families regarding discharge decisions and staff unawareness of relevant policies.
Addressed to: Kent and Medway NHS Social Care Trust
AI-generated concerns summaryThe coroner identified a lack of HSE guidance for historic and heritage equipment, much of which remains unguarded and poses significant safety risks.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner identified a concern about potential driver distraction from high-volume music in heavy machinery and the lack of a policy on its use. The report also notes the absence of random drug testing for heavy machinery operators.
Addressed to: Haulage Contractors Limited
AI-generated concerns summaryThe coroner noted an apparent lack of policy for referring patients in prolonged social isolation to mental health services, with a referral occurring only after family prompting. There were also discrepancies between nursing nutrition records and the observed practice of the catering team, alongside a delay in dietician referral despite …
Addressed to: Midlands Partnership NHS Trust
AI-generated concerns summaryThe coroner identified a lack of a nursing care plan for a patient with a history of drug use, insufficient search procedures, and confusion around the hospital's missing person policy. The patient's drug chart was also lost.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner noted that relevant information regarding Mr Grainger's falls history could not be shared between agencies due to system limitations, hindering cohesive multi-agency working. This led to a failure to properly request, review, and retain copies of falls risk assessments.
Addressed to: Derbyshire County Council; Milford House Care Home; NHS Southern Derbyshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner asked the highway authority to review the safety of a road bend, suggesting additional measures such as illuminated signs or rumble strips, and noted that chevron boards were dirty, indicating potential maintenance issues.
Addressed to: Staffordshire County Council
AI-generated concerns summaryThe coroner noted failures to correctly diagnose and treat symptoms suggestive of sepsis, the discharge of an unwell patient without completed tests, and gaps in the system for ensuring patients receive the Men ACWY vaccination.
Addressed to: Maidstone & Tunbridge Wells NHS Trust; NHS England
AI-generated concerns summaryThe coroner sought information on additional learning, specifically regarding timescales for implementing refresher training on the maintenance of lead attachments for monitors to ensure optimal performance.
Addressed to: GE Healthcare; South Tyneside and Sunderland NHS Trust
AI-generated concerns summaryConcerns included poor record keeping, inadequate conduct of multi-disciplinary team meetings, and staff lack of awareness about Clozapine's significance and side-effects. The Serious Incident Review process also contained significant inaccuracies.
Addressed to: Department of Health and Social Care; Midlands Partnership NHS Foundation Trust