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 identified a lack of consultant physician support for neurosurgical patients, especially for junior doctors implementing alcohol withdrawal regimens, and a difficult-to-understand alcohol withdrawal protocol that led to incorrect medication.
Addressed to: University Hospital Coventry and Warwickshire NHS TRUST
AI-generated concerns summaryConcerns relate to the common practice of operatives issuing tickets close to reversing trucks during spoil removal, which increases risk. The coroner suggests exploring technological solutions to avoid this proximity.
Addressed to: Waste Industry Safety & Health Forum
AI-generated concerns summaryThe coroner identified incomplete and inaccurate GP consultation notes, specifically noting missing records of a chest examination, the patient's lithium medication adherence, and a swallow test. There was also a discrepancy between recorded and verbal medication instructions.
Addressed to: Eden Park Surgery
AI-generated concerns summaryThe coroner identified inadequate fire hazard warnings on packaging for paraffin-based emollients, insufficient awareness among healthcare professionals, and a lack of consistent advice and data collection regarding their safe use.
Addressed to: Bradford District Care Foundation Trust; Department of Health and Social Care; Diprobase Bayer Public Limited; Medicines and Healthcare products Regulatory Agency; NHS England; NHS Improvement; Alliance Pharmaceutical
AI-generated concerns summaryThe coroner noted the absence of live CCTV monitoring for staircases and communal areas, and raised concerns about the lack of key fob access control for the staircase and an alarm if the stairgate is left open.
Addressed to: Crossroads House Care Home
AI-generated concerns summaryThe coroner identified several medication errors, including duplicate antiplatelet prescribing and an incorrect aspirin dosage, alongside a delay in documenting a prescribing decision. Concerns were also raised about insufficient clinician training in the medicines database and a nurse's failure to follow incident reporting protocol for errors.
Addressed to: Isle of Wight NHS Trust
AI-generated concerns summaryThe coroner noted that an X-ray report was ignored and no CT scan was performed before discharge, meaning decisions were made without a definitive diagnosis. The report also describes the lack of documentation for new protocols regarding CT scanning.
Addressed to: City Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted an inappropriate patient observation regime without clear record-keeping, a lack of comprehensive risk assessment, and staff not routinely consulting patient records. Additionally, concerns were raised regarding insufficient training for staff.
Addressed to: SHSC
AI-generated concerns summaryThe coroner noted a lack of national guidance for clinicians on the co-prescribing of multiple highly addictive and potentially harmful drugs. This absence of guidance increases the risk of combined drug toxicity, which the coroner believes could be mitigated by specific guidance.
Addressed to: Department of Health and Social Care; Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner identified inadequate communication and delays in assessing blood test results, alongside missed opportunities for earlier antibiotic treatment and recognising the development of sepsis.
Addressed to: Care Quality Commission; Russell Hall Hospital
AI-generated concerns summaryThe coroner sought assurance regarding rigorous trust policies surrounding clinical decisions, such as returning shoelaces to patients. Concerns were also raised about the dreary physical environment of the rooms, which contributed to patient boredom.
Addressed to: Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryThe coroner identified the absence of street lighting on the A5O and noted that lighting in this area would be beneficial for preventing future deaths.
Addressed to: Balfour Beatty Route Manager; Highways England
AI-generated concerns summaryThe coroner noted insufficient communication during transfer of care, alongside multiple deficiencies at Persona including inadequate pre-admission assessments, unsafe medicine administration practices, staff inability to recognise deterioration, and a lack of monitoring policies.
Addressed to: Bury Metropolitan Borough Council; Persona Care and Support Ltd
AI-generated concerns summaryThe coroner raised concerns regarding delays in urgent head injury assessment and transfer to specialist neurosurgical care, especially during public holidays. Additional issues included a lack of interventionist radiologists and inadequate software for electronic radiology transfer to out-of-area specialist centres.
Addressed to: Cardiff and Vale University Health Board; Cwm Taf University Health Board; NHS Wales Shared Services Partnership; Welsh Ambulance Services NHS Trust
AI-generated concerns summaryThe coroner noted a communication breakdown between mental health teams led to a patient not receiving follow-up care. Concerns were raised that high staff caseloads and chronic underfunding of mental health services continue to pose a risk.
Addressed to: Birmingham Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner identifies a lack of a mechanism to alert other agencies when a high-risk offender is released after completing their full sentence, which hinders effective risk management.
Addressed to: Home Office; MOJ
AI-generated concerns summaryThe coroner noted a lack of accommodation support for the deceased following his release from prison. Additionally, urgent messages regarding threats to self-harm were not picked up due to no weekend cover or divert system for the Integrated Offender Manager's phone.
Addressed to: Staffordshire Police; Ministry of Justice
AI-generated concerns summaryThe coroner identified a seven-day delay by the Prison and Probation Service in communicating a prisoner's correct release date to HMP Lewes. This prevented timely notification to the prisoner, an issue of particular importance for vulnerable individuals.
Addressed to: Prison and Probation Service
AI-generated concerns summaryThe coroner identified dangerous pool cleaning practices due to lack of equipment, insufficient staff training in water safety and rescue, and ineffective emergency alarm and communication protocols that hindered a timely response.
Addressed to: Bannatyne Group
AI-generated concerns summaryThe coroner identified inadequate allergen labelling and a lack of coordinated monitoring for allergic reactions at Pret-a-Manger, alongside concerns about Epipen auto-injectors having insufficient needle length and a lower adrenaline dose than recommended.
Addressed to: Department for the Environment, Food and Rural Affairs; Medicines and Healthcare products Regulatory Agency; Pfizer; Pret-a-Manger