Browse 6,488 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 significant delays in mental health referrals due to misdirection and loss, and frequent delays in delivering clinic letters from the mental health trust to the GP. This caused challenges for GPs in rapidly and accurately implementing specialist-directed medication changes, indicating a need for improved inter-agency communication and …
Addressed to: North East London Trust; Fullwell Cross Medical Centre
AI-generated concerns summaryThe coroner noted insufficient ward cover due to staff taking breaks simultaneously, leaving the deceased unsupervised before a fall. The report also highlights that this practice continued despite being identified in a serious incident report.
Addressed to: Bristol NHS Trust
AI-generated concerns summaryThe coroner noted the circumstances where an individual on hourly mental health checks was found deceased shortly after a check, having used a bedsheet and a light fitting as a ligature point.
Addressed to: HM Prison and Probation Service; Ministry of Justice; The Chief Coroner of England and Wales
AI-generated concerns summaryThe coroner identified a lack of continuity in care and inadequate independent family consultation regarding risks upon discharge. Additionally, there was insufficient clarity in the referral for psychiatric review and no evidence that the Trust's recommended actions were implemented or shared nationally.
Addressed to: South London and Maudsley NHS Trust
AI-generated concerns summaryThe coroner noted a lack of supporting documentation and consideration of risk factors when suspending an employee, with no evidence of referral to support services. Additionally, the approach to whistleblowers and their support was unclear.
Addressed to: IMI (Institute of the Motor Industry); LTE Group
AI-generated concerns summaryThe report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Addressed to: BUPA UK; CARE QUALITY COMMISSION; Medicines and Healthcare Products Regulations Authority; Performance Health
AI-generated concerns summaryThe coroner noted insufficient safety features for button batteries in household devices and a lack of understanding of their risks. Concerns were also raised about non-compliance with policies for young children in emergency services, inadequate medical assessments, and poor information sharing across NHS services.
Addressed to: The Royal Society for Prevention of Accidents; Healthcare Safety Investigation Branch; Department of Health and Social Care; NHS England; Secretary of State for business
AI-generated concerns summaryThe coroner identified a lack of robust care planning and single clinician oversight. Concerns were also raised about the emergency appointment triage system, including a patient being turned away without clinical assessment and critical medical notes not being prominently displayed or shared.
Addressed to: Aneurin University Health Board; Grange Clinic
AI-generated concerns summaryThe coroner identified inconsistencies in risk assessment and its application to granting leave, noting a significant delay in police notification for an absconded patient due to a 'period of grace' in the existing policy.
Addressed to: Oxleas Mental Health Trust
AI-generated concerns summaryThe coroner noted a nearly three-month delay in sending a doctor's letter to the patient's GP about severe aortic stenosis, due to challenges in obtaining medical records and administrative processing. This raises concerns about future deaths if similar communication delays occur.
Addressed to: Graham Street, Beswick, Manchester; Wythenshawe Hospital
AI-generated concerns summaryThe coroner noted that junior doctors at Pennine Acute NHS Trust were routinely ignoring automated ECG printout summaries, which meant these printouts were not informing clinical interpretation and judgment.
Addressed to: Pennine Acute NHS Trust
AI-generated concerns summaryThe coroner identified that the poor resolution and quality of the CCTV system on the bridge prevented accurate monitoring of individuals' behaviour, potentially hindering timely intervention in emergencies.
Addressed to: Humber Bridge Board
AI-generated concerns summaryConcerns were raised about the Emergency Department's system for discharge letters, which relies on junior doctors manually transcribing blood results, leading to an incorrect statement about normal bloods. This process also limits GPs' ability to perform trend analysis.
Addressed to: Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe falls risk assessment tool was outdated, and recorded risk levels did not match the assessment score. The buzzer system's limitations could delay assistance, and poor communication with the family reduced their confidence in care.
Addressed to: Hylton View Care Home
AI-generated concerns summaryThe coroner noted concerns regarding poor prescribing practices for oxygen, with a significant percentage of patients receiving supplementary oxygen without a valid prescription. This poses a risk that patients may receive inappropriate oxygen levels, potentially increasing mortality.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a delay in performing a CT scan within 8 hours for an elderly patient on multiple blood thinners after a fall, with expert evidence suggesting delayed symptom onset. Additionally, communication with the patient's son about deterioration signs was insufficient given language barriers.
Addressed to: Homerton University Hospital; N.I.C.E
AI-generated concerns summaryThe coroner noted that genetic test results indicating a pathogenic gene mutation were misinterpreted, leading to a family being incorrectly informed the results were "absolutely normal." This situation carries a risk of similar miscommunications impacting other children.
Addressed to: Great Ormond Street Hospital; Royal London Hospital
AI-generated concerns summaryThe coroner noted inadequate pre-discharge communication between the hospital and GP regarding melatonin prescription, leading to the patient's unawareness and a risk of sourcing from unlicensed online sources. Inconsistent CCG prescribing guidelines also created uncertainty for GPs.
Addressed to: Stockport Clinical Commissioning Group; Department of Health; Heaton Moor Medical Practice; Mayor of Greater Manchester; Pennine Care NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a National NHS England framework for private providers of locked rehabilitation units. This can lead to delays in placing patients with complex needs, who then remain in inappropriate wards while awaiting transfer.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that robust measures are not consistently in place to reduce miscommunication between ward staff and on-call doctors. This includes the absence of a consistent communication paradigm (such as SBAR) for telephone conversations.
Addressed to: Pennine Care NHS Trust