Browse 6,471 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted concerns regarding medication procedures after warfarin was administered in error, staff's ability to handle emergencies, and the lack of readily available medical history for ambulance staff.
Addressed to: PJ Care
AI-generated concerns summaryA large window in a flat lacked a restrictor device, creating a fall hazard for individuals attempting to close it. This potential hazard may also be present in other windows within the flat complex.
Addressed to: Radcliffe Investment Properties
AI-generated concerns summaryInsufficient maintenance of temporary rope barriers and absence of permanent barriers were noted at specific cliff-side 'hot spot' sites. Concerns also included a lack of internationally recognisable and general warning signs, and low uptake of RNLI staff training.
Addressed to: Cornwall Council; Heritage Attractions Ltd; Lands End Resort
AI-generated concerns summaryThe coroner noted staff did not fully understand the gravity of choking risk, and the care home's measures for informing visitors about safe food provision were insufficient, lacking robust written procedures.
Addressed to: Twinglobe Care Homes Limited
AI-generated concerns summaryA high temperature in a young child following a burn did not trigger an urgent hospital referral or subsequent recording by a hospital nurse when reported, resulting in no advice for parents. The coroner suggests reviewing information for other health professionals.
Addressed to: Chelsea & Westminster Hospital; Medical Protection Society
AI-generated concerns summaryThe practice of issuing antibiotics and steroids to COPD patients without a consultation lacks explicit advice for patients to seek medical help if their condition does not improve after starting the medication.
Addressed to: Denton Medical Centre
AI-generated concerns summaryThe coroner raised concerns regarding the processing and follow-up of Multi-Agency Safeguarding Hub (MASH) reports by mental health services, noting a lack of an effective system to ensure these referrals are acted upon.
Addressed to: Surrey & Borders Partnership NHS Trust; Surrey County Council; Surrey Police
AI-generated concerns summaryThe coroner identified gaps in monitoring haemoglobin levels, as daily blood tests were not consistently performed according to the care plan. Additionally, there was a lack of escalation and appropriate action when Early Warning Scores reached required thresholds.
Addressed to: Queens Elizabeth Hospital NHS Trust
AI-generated concerns summaryA partially blocked drain in the central reservation caused water to cascade across the carriageway, contributing to a collision. The coroner also noted that extending the barrier on the nearside might have prevented a vehicle from leaving the road.
Addressed to: Devon Highways
AI-generated concerns summaryObservation protocols on the ward were not followed for Mr Dickens, who was not seen for an extended period, and observation log entries were retrospectively made after his death without indicating their non-contemporaneous nature, undermining patient safety.
Addressed to: South London & Maudsley NHS Trust; The Care Quality Commission
AI-generated concerns summaryThe coroner notes a failure to communicate Care Plans and changes in writing, and a lack of clear routes for challenging these changes or for raising concerns in both emergency and non-emergency situations.
Addressed to: South London & Maudsley NHS Trust; Southwark Safeguarding Children Board; Steel & Shamash Solicitors
AI-generated concerns summaryThe coroner noted no clear evidence that all unspent Fentanyl patches were returned or discarded appropriately. Staff also did not fully consider the potential impact of a patient taking additional prescribed medication alongside illicit drugs.
Addressed to: Gloucestershire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted gaps in communication and information sharing between the Steps to Wellbeing Service and the Community Mental Health Team, as a crucial risk assessment was not conveyed. Concerns were also raised about inconsistent access to and updating of shared patient records by staff across services.
Addressed to: Dorset Healthcare University Hospital NHS Trust
AI-generated concerns summaryThe coroner is concerned that an excessive number of service users for mental health professionals might lead to inadequate levels of attention and care, potentially increasing the risk of future deaths.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that high patient numbers in the Emergency Department prevented staff from providing adequate care and monitoring, leading to delayed doctor assessments and a risk that patient deterioration may go unrecognised.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the transfer of information between hospitals, including recent falls not being documented in the discharge letter and a lack of nurse-to-nurse handover, potentially impacting the receiving hospital's assessment of the patient.
Addressed to: Staffordshire & Stoke-on-Trent Partnership NHS Tru; Leek Moorlands Hospital; Royal Stoke University Hospital
AI-generated concerns summaryThe coroner noted insufficient communication with the family regarding psychiatric care and discharge, and a shortage of care coordinators meant the patient lacked advocacy. A risk assessment also failed to address periodic impulsivity.
Addressed to: Livewell South West
AI-generated concerns summaryThe coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Addressed to: Birmingham & Solihull Mental Health Trust
AI-generated concerns summaryConcerns were raised about the safety of operatives working in restricted spaces near rotating industrial saws and the continued passing of machines on tracks 11 and 12 with limited gaps, despite expert criticism.
Addressed to: Treanor Pujol Limited
AI-generated concerns summaryThe coroner noted a lack of repeat blood tests for potassium levels as recommended by a consultant, and inadequate communication by nursing staff with the family regarding the patient's decline.
Addressed to: Dudley NHS Trust