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 raises concerns about the appropriateness of protective safety measures on North Bridge, Halifax, and highlights the need to urgently consider implementing immediate measures to prevent future fatalities.
Addressed to: Calderdale Council
AI-generated concerns summaryThe coroner raised concerns regarding the appropriateness of urgent preventative measures on the bridge to prevent similar future incidents.
Addressed to: Calderdale Council
AI-generated concerns summaryThe coroner highlighted that handovers for prisoners undergoing detoxification must include all patients and a registered nurse's review of records. Further concerns related to ensuring observations are taken closer to medication dispensing times to inform staff.
Addressed to: Bristol Community Health
AI-generated concerns summaryThe coroner noted significant deficiencies in how agency care staff recorded information on Hilltop Hall's electronic system, with entries often lacking specific staff identification, compromising record integrity and continuity of care. This issue had been previously raised by the local authority, and assurances of resolution appear not to have been …
Addressed to: Harbour Healthcare Limited
AI-generated concerns summaryThe coroner noted four fatal road traffic collisions at a specific site over 10 years, despite a speed limit reduction, and that no final decision has been made on a proposed casualty reduction scheme for the area.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner noted that the mental health team lacked access to the EMIS database for referencing GP data, which affected the information gathering process. The report recommends reviewing operational systems to facilitate such access.
Addressed to: South West Yorkshire NHS Trust
AI-generated concerns summaryThe coroner identified gaps in the supervision of care coordinators. Concerns also arose regarding maintaining continuity of care during staff absences and the lack of robust processes for managing Care Programme Approach meetings.
Addressed to: Oxford Health NHS Trust
AI-generated concerns summaryThe Trust's search policy contained ambiguity between 'advanced' and 'intimate' searches, leading staff to believe they could not ask patients to remove outer clothing like a bra for searching. This policy gap may extend to other Trusts.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of clarity for prison officers on when to initiate a Code Blue for chest pain. Additionally, critical updates on the patient's deteriorating condition were not relayed to the ambulance service, affecting response priority.
Addressed to: HMP Ryehill
AI-generated concerns summaryA 'Safer Cell', intended for reduced risk, contained an obvious ligature point due to an inwardly opening window. The coroner suggested design solutions could remove this risk.
Addressed to: HM Prison Bedford
AI-generated concerns summaryThe coroner noted the absence of a national Paediatric Early Warning Score (PEWS) system, which results in different systems across trusts and creates challenges for staff when children move between institutions.
Addressed to: NHS England; Secretary of State for Health
AI-generated concerns summaryThe coroner identified inadequate out-of-hours emergency mental health services and noted that the emergency referral policy was not fully understood by all medical services in Milton Keynes.
Addressed to: Central and North West London Hospital NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a clear process or protocol for prescribing medication to stop lactation for breastfeeding mothers following the unexpected loss of their child, which compounded the mother's psychological distress.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified issues with insufficient time for GP psychiatric assessments and a lack of clarity among professionals regarding mental health patient pathways. Concerns were also raised about the extent to which care coordinators can exercise clinical judgment.
Addressed to: Devon Local Medical Committee; Livewell Southwest; NHS England
AI-generated concerns summaryElectronic mental health records were unclear, making vital history difficult to find and extract, and a past suicide attempt was not recorded in the care plan. Communication gaps between mental health teams and the general practitioner meant the GP lacked relevant recent history.
Addressed to: Southern Health NHS Trust
AI-generated concerns summaryThe Trust's Standard Operating Procedure for communicating abnormal coagulation results lacks clarity for laboratory staff, potentially delaying results reaching healthcare professionals. Additionally, discharge summaries provided to GPs do not include blood test results, removing a potential safeguard.
Addressed to: Care Quality Commission; Epsom & St Helier University Hospital NHS Trust
AI-generated concerns summaryThe coroner identified delays by the Health Board in concluding its investigation and formulating an Action Plan for Mr Welton's death, with agreed implementation timescales not met. Concerns were also raised about the Health Board's general timeframes for Serious Incident Reviews and subsequent Action Plans.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryConcerns relate to the care home's inadequate falls risk assessment and failure to implement prevention measures or resubmit an action plan. The Falls Prevention Service did not proactively follow up, placing the onus on the patient to arrange further appointments.
Addressed to: Avenue House Nursing and Care Home; Care Quality Commission; Kettering General Hospital; Northamptonshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified inadequate cycle lane provision and protection for cyclists at the Latchmere Road and Elspeth Road junction, noting issues with a yellow box. Further concerns included a lack of cycle lanes, narrow road width, and a dangerous dip affecting cyclists on Lavender Hill immediately past the junction.
Addressed to: Transport for London; Wandsworth, Merton, Richmond and Sutton Borough Council
AI-generated concerns summaryThe coroner noted concerns that carers used a hoist for pressure relief, a practice not recommended by healthcare professionals or manufacturers, and that staff lacked sufficient training in moving and handling and pressure relief.
Addressed to: Elizabeth House (Oldham) Limited