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 report identifies concerns regarding the West London Mental Health Trust's Discharge Medication Summary and 7-Day Follow-Up processes, noting they need to be redrawn. Issues were also raised about the system for collecting, recording, and disseminating information.
Addressed to: Shepherds Bush Medical Centre; West London Mental Health Trust
AI-generated concerns summaryAmbiguous language used for urgent referrals is open to misinterpretation, and there is no provision for direct clinical staff input in setting urgent appointments or a checking procedure to guard against errors.
Addressed to: Medway NHS Trust
AI-generated concerns summaryRochdale Borough Housing Limited does not routinely install carbon monoxide detectors in its rented residential accommodation, creating a risk of future deaths.
Addressed to: Rochdale Borough Council
AI-generated concerns summaryThe coroner identified that Patients' Own Drugs (PODS) were left unsecured in the Emergency Department and on wards, risking misuse or theft. Concerns were also raised about policies not being followed and an unclear timeline for the implementation and staff awareness of updated policies.
Addressed to: Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner noted the jury's view that proper systems were lacking for prison healthcare staff to be trained and authorised to administer diazepam when a prisoner is suffering from controlled drug abuse.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified issues with '111' and EMAS call triaging systems not adequately prioritising potential sepsis and neurological symptoms. Concerns were also raised about the high thresholds and override capabilities within the EMAS Capacity Management Plan.
Addressed to: 111 Service; East Midlands Ambulance Service
AI-generated concerns summaryThe coroner raises concerns about persistent, unacceptable delays in patient handovers at the emergency department, causing patients to wait in ambulances and making resources unavailable. These issues have continued despite multiple previous reports and assurances.
Addressed to: Betsi Cadwaladr University Health Board; Welsh Ambulance Services NHS Trust; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted a culture of not recording contemporaneous notes, particularly concerning suicidal ideation, and that junior doctors could discharge patients without senior consultation. Informal communication between staff meant important messages were not formally recorded or considered at ward rounds.
Addressed to: Norfolk and Suffolk NHS Trust
AI-generated concerns summaryThe coroner noted a lack of supervision for members of the public at station premises, raising concerns about the absence of oversight at unmanned stations, especially for vulnerable individuals.
Addressed to: Network Rail
AI-generated concerns summaryInsufficient staffing in the acute dietetic service led to delayed referrals. The coroner also identified the need for mandatory training for nursing staff on a specific nutritional diagnostic tool and clarified procedures for acting on doctor referrals.
Addressed to: West Wales General Hospital
AI-generated concerns summaryThe coroner noted this was not the first road traffic death at this location, where the road surface standard had been below Highways Agency specifications for three years and likely contributed to the death.
Addressed to: Worcestershire County Council
AI-generated concerns summaryThe coroner identified an inadequate Mental Health Act assessment, which lacked collateral history, proper risk formulation, and collaborative safety planning. Concerns were also raised about the absence of a mechanism for nurses' input and a failure to implement identified operational improvements.
Addressed to: Greater Manchester Mental Health NHS Trust; Manchester Royal Infirmary
AI-generated concerns summaryThe coroner noted that three-bedded dormitory accommodation at the Campbell Centre was inappropriate for mental health patients, causing additional stress, and recommended a review of the facilities to meet modern standards.
Addressed to: Milton Keynes Clinical Commissioning Group
AI-generated concerns summaryA full Mental Health Act assessment was not performed before discharge, despite police concerns about suicidal intent. The coroner also noted a lack of clear inter-agency discharge protocols and insufficient facilities for mental health crisis management in Milton Keynes.
Addressed to: Milton Keynes Clinical Commissioning Group
AI-generated concerns summaryThere was a significant 3-hour delay in dispatching an ambulance to Mr. Collins, despite urgent clinical priority due to his rapidly deteriorating condition, because of a lack of available resources.
Addressed to: Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the content of police training on restraint and Appropriate Adult responsibilities. They also noted the need to review the criteria for identifying a suitable place of safety and transport responsibilities for individuals detained under Section 136 MHA.
Addressed to: Dyfed Powys Police; Hywel Dda Health Board; National Police Chief’s Council
AI-generated concerns summaryThe coroner raised concerns regarding ambulance delays caused by road closures for a public event, noting that crews were unclear on their authority to cross closures. The report also identified a need for event organisers to facilitate emergency vehicle access and for clearer signage at crossing points.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner noted a national shortage of suitable care provisions for individuals with complex mental health needs, particularly for those of Mrs Hadfield's age, making it difficult to find appropriate placements outside of mental health wards.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that staffing levels on Ward J83 may be insufficient for complex patient needs, impacting the implementation of treatment plans like meal assistance. Concerns were also raised about inadequate communication with families and inconsistent nursing records.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about unsafe loose kitchen floor tiles acting as a trip hazard for a frail resident. Welfare visits by the diocese did not include health and safety or risk assessments, despite the resident's known frailty and history of falls, indicating a broader risk for other 'grace and …
Addressed to: Diocese of Westminster; the Roman Catholic Church of England and Wales; Patrick Stead Hospital