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 a lack of remote access to medical records for on-call psychiatry doctors, insufficient family involvement in care planning for mentally unwell patients, and an absence of self-harm training for frontline hospital staff.
Addressed to: Leicestershire NHS Trust; University Hospitals Leicester NHS Trust
AI-generated concerns summaryThe coroner noted that despite existing measures, individuals can still too easily access multiple prescriptions from different GP surgeries, which creates risks of excessive intake and diversion of prescription drugs to the illegal market.
Addressed to: Devon Local Medical Committee; NHS Northern Eastern and Western Devon Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted a suggestion for compulsory 'black box' installation in vehicles driven by young drivers aged 17-25, believing this measure could prevent future deaths and sought views on its implementation.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted insufficient communication between the District Nursing team, family members, and carers, alongside issues with the availability of nursing records. This limited opportunities for timely interventions and decision-making regarding Mr Smith's treatment.
Addressed to: Virgin Care Services Limited
AI-generated concerns summaryThe coroner noted a lack of communication between police forces regarding primacy for a missing person report. There was also a significant delay in actioning an email transfer of the case due to it being sent to a generic address, highlighting a need for verbal confirmation.
Addressed to: National Police Chiefs' Council; Warwickshire Police; West Midlands Police
AI-generated concerns summaryThe coroner noted insufficient awareness among patients and care organisations regarding the fire hazard of paraffin-based skin products combined with smoking and airflow mattresses. Concerns were also raised about the lack of risk assessments and an operational smoke detector.
Addressed to: Care Quality Commission; Skillsforcare; Home Office
AI-generated concerns summaryThe provided text for the Coroner's Concerns section is malformed and does not contain any identifiable specific concerns raised by the coroner.
Addressed to: Brighton and Hove Clinical Commissioning Group; North Laine Medical Centre
AI-generated concerns summaryThe coroner noted the similar appearance of Fungizone and Ambisome drug vials, which increases the risk of confusion and potential toxicity. Concerns were also raised regarding nursing checks being passive rather than active.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raises concerns about persistent ambulance delays, emergency department admission delays, resource availability, and patient flow issues. These recurring problems continue to place patients' lives at risk despite previous reports.
Addressed to: BCUHB; HM Stanley Site; Welsh Ambulance Services NHS Trust; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner identified that Shropdoc staff lacked access to GP records, affecting treatment decisions. Concerns were also raised about inadequate A&E staffing levels, delays caused by out-of-stock medication, and failure to follow sepsis protocols.
Addressed to: Shropdoc; Shrewsbury and Telford Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a lack of mandatory instruction and testing in partial loss of engine power scenarios for light aircraft pilot licenses, despite evidence that these situations present significant challenges and contribute to crashes.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted no action had been taken since 2018 to address safety risks at a high-speed railway foot crossing. Recommended measures include an enclosed footbridge, enhanced fencing, repeater lights, and trespass deterrence.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted a history of suicidal falls from multi-storey car parks in Swindon, including Fleming Way. Concerns were raised about the absence of physical barriers to prevent jumping and the lack of Samaritans contact information at these sites.
Addressed to: Swindon Borough Council
AI-generated concerns summaryThe coroner identifies that a nurse may not fully understand when it is appropriate to carry out CPR on a flat surface and does not know how to deflate patient mattresses in an emergency.
Addressed to: RCN Legal Services; New Lodge Nursing Home
AI-generated concerns summaryThe coroner noted an unclear process for repeat blood samples in babies and a lack of system to highlight abnormal test results. Additionally, parents received insufficient clear advice on discharge regarding indicators of their baby's health.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryConcerns were raised regarding the individual's inability to access mental health support while receiving dependency treatment, due to a dual diagnosis approach, and their discharge from CMHT following missed appointments.
Addressed to: Cornwall NHS Trust; NHS Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified a lack of a reminder system for measuring venous blood gases, as per the Sepsis Six Pathway, which affected decisions on escalating respiratory support. Concerns were also raised regarding an insufficient number of machines available to provide PEEP.
Addressed to: Dorset County Hospital
AI-generated concerns summaryThe coroner noted significant waiting times for CBT, reaching 12 months against a 6-week target due to insufficient capacity. The report also described ineffective escalation mechanisms between the commissioning body and service provider to address the increasing waiting list.
Addressed to: Pennine NHS Trust; Tameside and Glossop Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted the absence of a system to monitor West Midlands taxi drivers for driving over drug limits, which police identified as necessary for passenger safety.
Addressed to: Birmingham City Council; Sandwell Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding an unsafe method of work for accessing the cellar and insufficient guarding of the cellar steps to prevent accidental public entry.
Addressed to: Joseph Holt Ltd.; Brewery