Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified inadequate planning for the patient's discharge, including the absence of a 'best interests' meeting, despite unresolved medical issues. Concerns were raised that precipitous hospital discharges are not uncommon and may compromise patient safety.
Addressed to: Mid Yorkshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner notes police officers lack knowledge of choking risks for suspects who have swallowed drugs during detention. Additionally, provided mouth and face guards are defective and inappropriate for high-risk suspects, meaning they are not carried or used.
Addressed to: ACPO; Bedfordshire Police
AI-generated concerns summaryThe coroner identified issues with the universal availability and access to Detainee Property and Medical Forms (DPMFs) and other medical records for healthcare staff within the prison system. There was no assurance that medical assessments from custody were consistently seen and considered by prison medical staff.
Addressed to: Serco Ltd; Metropolitan Police Service; Oxlea NHS Trust; Thameside Prison
AI-generated concerns summaryThe coroner identified a lack of training for moderately senior doctors in making X-ray requests and the risk of CT requests remaining unattended for extended periods due to communication breakdowns, leading to significant delays in completing investigations.
Addressed to: NHS England
AI-generated concerns summaryConcerns were raised regarding special police officers' lack of tablets for system access and insufficient understanding of missing person processes and mental health protocols. Communication issues between officers and CAD operators, including search capabilities, led to a missed opportunity to identify a high-risk individual.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted insufficient communication at discharge regarding the need for anti-embolism stockings, inadequate patient advice on their correct use, and that the local policy does not fully reflect NICE guidelines.
Addressed to: University of Leicester Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding incomplete fluid charts, failure to administer prescribed potassium and intravenous fluids, and missed opportunities to monitor and recognise patient deterioration due to inadequate reading of notes during transfer.
Addressed to: Brighton & Sussex University Hospitals NHS trust
AI-generated concerns summaryInadequate governance was identified at Lancaster Lodge, including the lack of a registered manager, insufficient trained staff, and poor controls on resident documentation. The coroner also noted grossly inadequate leadership and oversight by the Board, impacting employment and communication procedures.
Addressed to: RCI; RPFI
AI-generated concerns summaryThe coroner noted a nurse was unaware of her responsibility for the ward and for initiating an immediate investigation, as this was not clearly communicated at handover. Concerns were also raised about the robustness of the initial investigation, which lacked staff interviews and detailed analysis of events.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner noted that staff recorded National Early Warning Scores (NEWS) but did not action them according to protocol, and a Mobile Medic request was marked complete without attendance. Concerns also included insufficient staffing impacting patient monitoring and record-keeping.
Addressed to: Bedford Hospital
AI-generated concerns summaryThe coroner noted a lack of communication among staff regarding pre-operative patient feeding and medication adherence, alongside concerns that porter availability affected the hospital's capacity to perform operations.
Addressed to: Wye Valley NHS Trust
AI-generated concerns summaryThe coroner highlighted repeated fatalities and accidents on the Westfield Lane carriageway near Hook, identifying the location as an accident blackspot requiring preventative measures.
Addressed to: ERYC; Highways Department
AI-generated concerns summaryThe coroner identified inadequate assessment of a patient's capacity to comprehend discharge information due to advanced dementia. Concerns also included delays in X-ray review and insufficient attempts to recall the patient, given challenges in contacting them and their GP.
Addressed to: Care Quality Commission; Royal United Hospital
AI-generated concerns summaryConcerns were raised regarding police officers' understanding and application of the Domestic Abuse policy, particularly terminology and the significance of non-fatal strangulation. The report also identified failures in placing police system markers, conducting adequate risk assessments, and the incomplete implementation of prior review recommendations.
Addressed to: Manchester Police
AI-generated concerns summaryThe coroner noted long waiting times for IAPT therapy, ranging from 12 to 18 weeks, which may lead to mental health deterioration or disengagement. Difficulties in contacting the IAPT team by telephone were also identified as a potential barrier to individuals seeking assistance.
Addressed to: North East London NHS Trust
AI-generated concerns summaryThe coroner identified that vulnerable young mothers who book maternity care late (after 28 weeks) are often excluded from the Family Nurse Partnership, thereby missing crucial support despite late booking being a risk factor for their child.
Addressed to: Whittington Health NHS Trust
AI-generated concerns summaryThe coroner noted issues with a patient's access to food and drink, delays in speech and language referrals, and a lack of assistance with toilet needs. Critical information about opioid sensitivity was not consistently recorded or flagged across hospital, GP, and care home notes.
Addressed to: Adelaide Medical Centre; Compton Lodge Care Home; Royal Free Hospital NHS Trust
AI-generated concerns summaryThe coroner identified a lack of timely medical review and formal mental capacity assessment for an informal patient whose condition was deteriorating and who was confused. Concerns were also raised regarding staff not regularly reading medical records and incomplete documentation of consent for off-licence medication.
Addressed to: Care Quality Commission; Department for Health; Oxleas NHS Trust
AI-generated concerns summaryThe coroner noted a lack of a clear national definition for cervical trauma, which leads to inconsistent approaches in investigating a history of cervical trauma and planning clinical treatment during pregnancy.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner noted that the electronic patient record system did not transfer critical information, such as suicidal thoughts reported during a triage call, to the screen seen by a doctor conducting a subsequent face-to-face appointment. This omission risked important patient information being overlooked.
Addressed to: Edgeley Medical Centre; Stockport Medical Group