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 noted that prior to the death, The Christie Hospital did not routinely test allogeneic stem cell transplant patients with infection signs for toxoplasmosis. The report suggests this learning should be shared nationwide with other specialist blood cancer care units.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted that current law does not mandate first aid training for care home staff or require carers to carry mobile phones to summon assistance without leaving a resident.
Addressed to: Care Quality Commission; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a more rapid steroid reduction rate was initiated than originally suggested, a delay in transmitting family concerns about the patient's condition to medical staff, and an additional decrease in steroid dose due to a prescribing error.
Addressed to: Newmarket Community Hospital; Rookery Medical Centre; West Suffolk Hospital
AI-generated concerns summaryThe coroner notes confusion regarding responsibility for vaccinating children who miss school programmes before university, especially as the MenW vaccination is an optional GP service. There is no clear audit to ensure GP practices identify and vaccinate these children.
Addressed to: NHS England; NHS London; Public Health England
AI-generated concerns summaryThe A&E department did not conduct further imaging for a significant head injury in a borderline case. A GP later did not take full observations for persistent back pain, potentially delaying diagnosis of a developing problem.
Addressed to: Audlem Medical Practice; Royal Stoke University Hospital
AI-generated concerns summaryThe coroner identified inadequate communication and history taking by the MHLS nurse, who did not record the patient's attempt to strangle himself or access a drugs trolley. Concerns were also raised regarding insufficient efforts to find a suitable bed for a high-risk patient.
Addressed to: Black Country NHS Foundation Trust; Care Quality Commission
AI-generated concerns summaryThe coroner noted a license for holding dance music events at Hoults Yard remains active, despite assurances no further similar events would occur. A robust internal protocol is recommended, requiring consultation with police and council licensing officers for any future events.
Addressed to: Hoults Limited; Shindig Events Limited
AI-generated concerns summaryThe coroner highlighted a need for Airedale Hospital to review discharge procedures for head injury patients, particularly regarding discharge papers. Additionally, Riverview Care Home was asked to review its procedures for referring patients to hospital with seizures following a head trauma.
Addressed to: Airedale NHS Foundation Trust; Riverview Nursing Home
AI-generated concerns summaryThe coroner's report raises concerns regarding the lack of suitable options available to police officers when dealing with heavily intoxicated individuals, leading to a person being left alone in a public lavatory on a cold night and subsequently dying.
Addressed to: Dyfed & Powys Police; Wiltshire Police; College of Policing; Council of Chief Police Officers; National Police Chiefs' Council; South Western Ambulance Service NHS Foundation Trust; Wiltshire Police HQ
AI-generated concerns summaryThe coroner identified poor understanding and adherence to failed visit procedures by Careworld staff, and a lack of clear keyholder information. Concerns also included inadequate record-keeping of welfare checks and no clear system for prioritising out-of-hours referrals.
Addressed to: Careworld London Limited; Tower Hamlets Borough Council
AI-generated concerns summaryThe coroner noted an inadequate response to the NHS 111 call made on the afternoon of 30th December 2017.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryInsufficient resources led to a significant delay in emergency service attendance for two vulnerable ladies who had fallen, with call takers not appreciating their worsening condition. There was also a lack of clinical oversight in the decision to stand down the ambulance service.
Addressed to: South East Coast Ambulance Services
AI-generated concerns summaryThe coroner noted ongoing issues with ambulance delays, emergency department admissions, resource availability, and patient flow. These persistent problems continue to place patients' lives at risk, despite having been reported on previously.
Addressed to: BCUHB; HM Stanley Site; Welsh Ambulance Services NHS Trust; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted significant delays in ambulance response for a priority 2 patient, with attendance taking nearly 1.5 to 2 hours against an 8-minute guideline, due to high demand and resource issues.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted that Dorset Police's firearms licensing procedure does not routinely include enquiries with family members or those living with an applicant. This omission risks missing vital information that could impact the decision to grant a firearms certificate, even when there is no evidence of domestic abuse.
Addressed to: Dorset Police; Home Office
AI-generated concerns summaryThe coroner identified ongoing issues with the use of prescription and illicit drugs at HMP Guys Marsh, noting that the chaotic medication dispensing process at the healthcare hatch allows for drug transfer and redistribution among prisoners.
Addressed to: Care UK; HMP Guys Marsh; HM Prisons and Probation Service
AI-generated concerns summaryThe coroner noted equipment failure due to inappropriate materials and a lack of accountability for annual inspections, particularly regarding unclear staff handovers. Concerns remain about potential recurrence of these organizational issues.
Addressed to: Tower Hamlets Borough Council
AI-generated concerns summaryThe coroner noted a discrepancy in understanding among nursing staff regarding the mandatory nature of clinical responses based on NEWS scores, with junior staff perceiving discretion. Concerns were also raised about the clinical appropriateness of the common practice of "re-triggering" patients under NEWS.
Addressed to: University Hospitals Bristol NHS Trust
AI-generated concerns summaryThe coroner identifies that a turnstile remains accessible to unauthorised personnel, including children, and notes the absence of a company contingency plan for staff to assist in searching for intruders. Further concerns are raised about the lighting equipment provided to site security officers.
Addressed to: Canary Wharf Group PLC
AI-generated concerns summaryThe coroner noted poor compliance with the Enhanced Care Supervision policy, resulting in missed assessments and care not provided according to identified risk, leaving patients vulnerable to falls. There was also a lack of action by the Trust following staff concerns about insufficient supervision resources.
Addressed to: Doncaster and Bassetlaw NHS Trust; Department of Health and Social Care; Secretary of State for Health