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 a policy for monitoring patient medication compliance and triangulating information in community settings. There were also concerns about poor and non-existent record-keeping, impacting communication and patient safety.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner raises concerns about current practice guidelines for clomipramine prescription and suggests considering routine blood screens for patients on long-term clomipramine.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner noted confusion regarding whether the approved building control inspector or the builder/owner is responsible for ensuring windows meet building standards, leading to the builder/owner believing standards were met after multiple inspections.
Addressed to: Construction Industry Council
AI-generated concerns summaryThe coroner raised concerns about whether patients, even with normal renal function, should receive intravenous fluids after a CT scan with contrast if they are subsequently required to be nil by mouth for several hours due to another procedure.
Addressed to: Medway NHS Trust
AI-generated concerns summaryThe coroner identified a lack of pathology sample tracking systems, inconsistent tracking of outstanding reports across hospital departments, and clinician reliance on slower paper reporting methods. Concerns were also raised about incompatible IT systems between trusts and national pathology backlogs causing delays.
Addressed to: Department for Health; Greater Manchester Strategic Health Group; Royal College of Pathologists; Stockport NHS Trust
AI-generated concerns summaryCare home assistants demonstrated a poor understanding of modified diets and the importance of escalating choking episodes to SALT. The system for preparing and marking food for residents with specific dietary requirements was also inadequate.
Addressed to: Care Quality Commission; Minister of State for Care
AI-generated concerns summaryThe coroner noted that undetected breech births are not uncommon, with pre-delivery scans not routinely performed due to facility and training limitations. There were also concerns about medical professionals not feeling comfortable challenging clinical decisions, despite believing them to be incorrect.
Addressed to: Department for Health; the Healthcare Safety Investigation Branch
AI-generated concerns summaryGP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotic medication, which can lead to relapse and increased risk of harm.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner identified a need for enhanced road markings, early warning signs, and longer filter lanes at the A40/Redstone Road junction. Consideration was also given to lowering the speed limit and introducing additional westbound filter lanes.
Addressed to: Economy and Transport; Department for Transport
AI-generated concerns summaryThe Assistant Coroner noted the absence of protective barriers at other local platforms, despite one being built at Herne Station. Concerns were also raised regarding the use of live rails at ground level for power supply, which increases contact risk compared to overhead cables.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified insufficient resources and financial provision leading to emergency ambulance services being unable to meet minimum performance standards. Concerns were also raised regarding a gap in high dependency transport provision and unmet performance targets for non-emergency transfers, which could put patients at risk.
Addressed to: Dorset Clinical Commissioning Group; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted insufficient recording and escalation of mental health concerns for a detainee, which prevented MASH referral and led to a superficial medical examination. Further concerns included inconsistencies in police statements and custody records regarding injuries and use of force.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner raises concerns that Mrs Perkin's discharge to the care home under the D2A scheme, when her needs were still being assessed, placed her at an increased risk of falls.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner noted that Brighton & Sussex University Hospitals NHS Trust's Transfer Policy was not adhered to, and care provided at Newhaven Downs was suboptimal.
Addressed to: Brighton and Sussex University Hospital NHS Trust
AI-generated concerns summaryThe LAS failed to properly record the deceased's symptoms, resulting in an incorrect priority decision and delayed attendance. Additionally, the LAS did not adhere to its own guidelines for returning a call to gather further medical details.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted a lack of follow-up for the patient after multiple emergency department admissions for alcohol dependence. There was insufficient information sharing between the Alcohol Liaison and Inclusion services, resulting in no coordinated treatment plan for his alcohol dependence.
Addressed to: Hampshire Hospitals NHS Foundation Trust; South Staffordshire & Shropshire NHS Trust
AI-generated concerns summaryThe coroner identified soldiers' unclear understanding of a specific gun drill, the Range Conducting Officer's insufficient knowledge of tank status, and inadequate risk assessments by BAE and MOD failing to identify a gun could fire without a safety assembly.
Addressed to: BAE Systems Ltd; MOD
AI-generated concerns summaryThe coroner raises concerns about soldiers' clarity regarding the "Prove The Gun drill" and the Range Conducting Officer's up-to-date knowledge of tank status. The report also notes the need for improved risk assessments during gun design, actively considering drills.
Addressed to: BAE Systems Ltd; MOD
AI-generated concerns summaryThe coroner raised concerns about inadequate scan time and formal recording procedures for confirming fetal demise after feticide, contributing to an unexpected live birth and unpreparedness of staff and parents. The report also identified a need for national guidance and a parent information leaflet.
Addressed to: Department for Health; Manchester University NHS Trust; RCOG
AI-generated concerns summaryThe coroner identified a lack of a system to ensure communication between specialty consultants regarding ongoing risks when planning simultaneous specialty-specific treatments.
Addressed to: Care Quality Commission; Manchester University NHS Trust; NHS England; Stockport NHS Trust; Alexandra Hospital