Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryConcerns were raised regarding the information provided to patients on discharge from hospital about the risk of thromboembolisms after recent surgery for trauma.
Addressed to: Bradford Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified issues with the security of commercial and communal bins, including unsecured lids and easily opened locks, making it foreseeable for individuals to seek shelter, particularly in dark or isolated areas. The report calls for clarification on what constitutes a 'secure' bin in formal guidance and for increased …
Addressed to: Chartered Institution of Waste Management; Environmental Services Associations; Health and Safety Executive; Local Government Association
AI-generated concerns summaryThe coroner raised concerns about the lack of a systematic and monitored training programme for clinical staff in sepsis identification and treatment. This is crucial given recurring issues identified in documentation, timely escalation of patient deterioration, and handovers.
Addressed to: Aintree University Hospital NHS Trust; Care Quality Commission; General Medical Council; NHS England; NHS South Sefton Clinical Commissioning Group; Nursing and Midwifery Council; Public Health England
AI-generated concerns summaryThe coroner identified a lack of clear protocols for managing missing persons, particularly high-risk individuals, and insufficient arrangements for seeking help from NHS services. Concerns were also raised about placing reporting responsibility on family and the need for updated staff training.
Addressed to: Head of Safeguarding
AI-generated concerns summaryThe coroner identified a lack of formal policy or procedure in Wales for reviewing and assessing voluntary patients before home leave, leading to reliance on undefined 'best practice'. There were also insufficient procedures for hospital staff to liaise with families and community psychiatric nurses regarding home leave preparedness and support.
Addressed to: ABMU Health Board
AI-generated concerns summaryThe coroner noted a driver's practice of only focusing directly ahead and minimising eye contact with other drivers when emerging from junctions, which was adopted to prevent other vehicles pulling out.
Addressed to: National Express West Midlands
AI-generated concerns summaryThe coroner identified a lack of direct communication between private therapy and the GP regarding the patient's welfare, and insufficient exploration of potential family support when professional help was not immediately available.
Addressed to: Harrogate & Rural District Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that event organisers did not identify a clearly visible high voltage power line over the Kendal Calling site and failed to take steps to minimise risk. This significant hazard was missed by both organisers and authorities, despite existing safety planning and licensing processes.
Addressed to: Department of Health and Social Care; Health and Safety Executive; Kendal Calling; The Secretary of State for Business
AI-generated concerns summaryThe national guidance for Clexane prescription after an operation does not account for patients with prolonged reduced mobility, nor does it emphasize reviewing their needs post-discharge.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryDelays in discharge and specialist letters led to unclear care responsibility and delayed assessments. The coroner also noted missing patient notes, a lack of clear guidance for community staff, and no protocols for complex paediatric care transfers.
Addressed to: Department of Health and Social Care; Healthcare Safety Investigation Branch; Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted gaps in training for staff regarding choking risks for mentally ill patients, issues with information dissemination in hospital records, and challenges in managing choking risks for patients eating in their bedrooms.
Addressed to: NHS Professionals Limited; Prospect Park Hospital
AI-generated concerns summaryThe coroner noted low staffing at HMP Leeds on the evening of 19th February 2016. On the morning of 20th February, low staffing levels meant no Landing Officer was present, preventing ACCT reviews for several hours.
Addressed to: HMPPS
AI-generated concerns summaryThe coroner expressed concern about the need to expedite measures for deterring tragedies at the location, particularly through the introduction of anti-climbing mesh and prominently displayed CCTV cameras overlooking the bridge.
Addressed to: Calderdale Metropolitan Borough Council
AI-generated concerns summarySome prison staff had not received cardiopulmonary resuscitation training, either initially or as refresher training, despite evidence highlighting its critical importance in early response.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner noted insufficient guidance for gym members on medical conditions and for staff assisting swimmers with epilepsy. Concerns also included inadequate pool supervision with CCTV issues, lack of poolside emergency equipment, and lapsed first aid certifications.
Addressed to: DW Fitness First; UK Active
AI-generated concerns summaryConcerns include that reduced doctor training and over-reliance on questionnaires may impede accurate diagnosis and risk assessment. There are also insufficient NHS services, beds, and parental support for individuals with Autistic Spectrum Disorder.
Addressed to: CNWL NHS Trust; Department of Health and Social Care; NHS England; Royal College of Psychiatrist
AI-generated concerns summaryThe coroner noted concerns regarding the free online availability of dangerous and addictive drugs, which can be prescribed without contact with a patient's regular doctor or access to their medical records, and potentially filled in UK pharmacies without further checks.
Addressed to: GPC; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the level of supervision for junior doctors on the ward, particularly when patients are discharged without examination by a more senior practitioner.
Addressed to: Gloucestershire NHS Trust
AI-generated concerns summaryConcerns were raised regarding Wide Care Alarm Service's staffing levels and policy for one-person responder units, which caused a delayed response to a fall. There were also gaps in sharing updated client information with third-party call centre contractors.
Addressed to: City Wide Alarms; Sheffield City Council
AI-generated concerns summaryThe coroner noted the lack of commissioned services for adult ADHD assessment, diagnosis, and treatment within Cornwall, along with practical difficulties in managing out-of-county referrals for ongoing medication oversight.
Addressed to: Kernow Clinical Commissioning Group