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 identified a shortage of suitable supported accommodation for individuals with Asperger's Syndrome and noted issues with an uninspected placement. Concerns were also raised about the Trust's poor communication, inadequate discharge planning and handover, and shortcomings in risk assessment.
Addressed to: Department of Health and Social Care; Somerset NHS Trust
AI-generated concerns summaryThe coroner noted shortcomings in telecare systems, including the lack of directly linked fire alarms, client communication with responders, and staff training for fire incidents. Issues were also raised regarding the slow launch of appliance safety campaigns.
Addressed to: Chartered Trading Standards Institute; Wandsworth Watch Alarm; Office for Product Safety and Standards; Wandsworth Borough Council; Whirlpool UK
AI-generated concerns summaryThe emergency department could not meet Manchester triage system time targets, and very young babies did not receive early clinical input from a paediatrician. The on-call consultant was not called in despite significant demand, as wait times did not trigger attendance.
Addressed to: Department of Health and Social Care; Mayor of Greater Manchester; NHS England
AI-generated concerns summaryThe coroner noted issues with multiple IT systems hindering information sharing and patient data capture across the Mental Health Trust and a hospital. Additionally, a necessary mental health support service could not be delivered due to commissioning limitations.
Addressed to: Pennine Care NHS Trust; NHS England; Tameside Clinical Commissioning Group; Tameside General Hospital; for Health
AI-generated concerns summaryThe Haven Day Care Centre began providing services without an adequate care plan or needs assessment from Durham County Council. The council's systems to prevent this were not consistently applied, and the care plan eventually implemented was incomplete and not discussed with the family.
Addressed to: Durham County Council; Haven Day Care Centre
AI-generated concerns summaryThe coroner noted a gap in communication where changes to a patient's mental health medication regime, supervised by the Crisis team, did not trigger corresponding action or review regarding their physical health medication.
Addressed to: Dorset University NHS Trust
AI-generated concerns summaryThe coroner raised concerns that the national speed limit on a bridge with restricted visibility and height limits may be too high, and there is no priority signage for high-sided vehicles needing the full carriageway.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryThe coroner notes insufficient consideration was given to the unique nature of the excavated path in the risk assessment, as it was the only direct route to houses, leading pedestrians to bypass barriers.
Addressed to: B & D Civil Engineering Limited; M & S Water Services
AI-generated concerns summaryThe coroner noted underfunding and long delays in mental health services for children and young people in Cumbria. This raises concerns about young people entering adulthood with unresolved mental health issues, leading to significant human and financial costs.
Addressed to: Cumbria Partnership NHS Foundation Trust; Department of Health and Social Care; Morecambe Bay Clinical Commissioning Group; North Cumbria Clinical Commissioning Group
AI-generated concerns summaryThere was no specific instruction for GP practices regarding the correct procedure for making referrals to the Urgent Care and Assessment team.
Addressed to: St Lukes Primary Care Centre
AI-generated concerns summaryThe coroner identified that care home staff were unaware of and did not follow SALT recommendations for resident supervision and dietary needs, leading to unsupervised mealtimes for those at high choking risk. Concerns also included inadequate incident reporting and disorganised care plan records.
Addressed to: HC-One
AI-generated concerns summaryThe coroner noted an unwitnessed and unreported fall, a lack of recording patient changes or informing family, and insufficient recognition of deterioration signs alongside an ineffective early warning system. The report also described un-updated care plans and incomplete records.
Addressed to: Department of Health and Social Care; HC-One
AI-generated concerns summaryThe EAM facility lacked a serious untoward incident protocol, and staff demonstrated insufficient ability to identify deteriorating patients, escalate medical reviews, or use care records effectively. Insufficient action had been taken on recommendations from a CQC inspection, without sustained improvement.
Addressed to: EAM Care Group
AI-generated concerns summaryThe coroner noted a lack of documentation for checking that unused trauma line taps were closed to air, and that the trauma lines themselves did not come with clamps to close unused lines.
Addressed to: Barts Health NHS Trust; Royal College of Anaesthetists
AI-generated concerns summaryThe coroner noted that payday loan companies contributed to the individual's situation by encouraging dependence on loans despite knowing he was dependent. Additionally, financial checks conducted by these companies were inadequate.
Addressed to: Financial Conduct Authority
AI-generated concerns summaryConcerns were raised regarding compromised visibility at a road junction, despite existing signage, and the lack of a timeframe for planned improvements such as renewed signing and rumble strips. The report also highlighted a recommendation for installing "Stop" signs.
Addressed to: Highways Agency; Northamptonshire County Council; Northamptonshire Highways
AI-generated concerns summaryThe East of England Ambulance Service faces demand that consistently outstrips its resources, a situation unchanged since 2017, with public demand deemed unsustainable. Significant delays in hospital handovers further reduce ambulance availability for emergency calls.
Addressed to: East of England Ambulance Service; Lister Hospital; Luton and Dunstable Hospital; Princess Alexander Hospital
AI-generated concerns summaryThe coroner noted concerns regarding aftercare and transition arrangements for patients discharged home with a moderate to high risk of self-harm, specifically highlighting the obligations for putting in place contact arrangements for these individuals.
Addressed to: NHS Kernov Clinical Commissioning Group
AI-generated concerns summaryConcerns were raised that a resident, assessed as high risk of choking and on a soft diet, was provided unsuitable food items and left unattended while eating.
Addressed to: Care Quality Commission; Harbour Health Care Limited; Hilltop Court
AI-generated concerns summaryThe coroner noted extremely poor lighting and a lack of CCTV in the area where Casper entered the canal, making it difficult to discern the canal from the surroundings and unclear what precisely happened.
Addressed to: Canals and Waterways Agency; Peel Holdings; Trafford County Council