Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner raises concerns that the Abdominal Aortic Aneurysm (AAA) screening programme's age criteria excluded Mr Abrahams, and notes that the asymptomatic nature of AAAs makes the benefits of opting in unclear to patients.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns that doctors may not be attempting all available contact numbers or leaving messages for patients in urgent situations. There is a need to update hospital guidelines, staff training, and GMC and Department of Health guidance on this practice.
Addressed to: Department of Health and Social Care; General Medical Council; St Georges Hospital
AI-generated concerns summaryThe Homeless Healthcare Team could not explain the criteria for emergency psychiatric assessment for a patient expressing self-harm and suicidal thoughts, and there was no evidence of follow-up after the patient missed an appointment.
Addressed to: Gloucestershire Care Services NHS Trust
AI-generated concerns summaryThe coroner noted significant delays in ambulance response times, including a 10-hour wait for a Category 3 call. EMAS indicated that insufficient funding and demand are causing unacceptable response times.
Addressed to: East Midlands Ambulance Service NHS Trust; NHS Hardwick Clinical Commissioning Group
AI-generated concerns summaryMedical staff did not attempt CPR after consulting the wrong set of medical notes.
Addressed to: George Eliot Hospital
AI-generated concerns summaryThe coroner identified that prison is not an appropriate environment for individuals with significant mental health problems. There is a noted lack of secure, therapeutic facilities focused on treatment, particularly within the female prison estate, a concern first raised a decade prior.
Addressed to: Department for Health; HM Prison Service
AI-generated concerns summaryEMAS call handlers lacked guidance for rapidly developing labour, and information sharing between Stepping Hill Hospital and EMAS was unstructured. Paramedics also lacked experience for the specific delivery and did not receive sustained expert support.
Addressed to: Department of Health and Social Care; East Midlands Ambulance Service; Healthcare Safety Investigation Branch; Stepping Hill Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the non-availability of Andexanet alfa, a reversal agent for Factor Xa inhibitor anticoagulants, in the UK, given the increasing clinical use of these drugs.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryMr Vukovic was referred to the Home Treatment Team but was not seen, and a referral to Lifeline lacked follow-up from Oxleas to ensure patient engagement. This led to his discharge from hospital without subsequent care.
Addressed to: Oxleas NHS Trust
AI-generated concerns summaryThe coroner noted a failure to contact a doctor, possibly due to a system issue, along with poor record keeping of vomiting incidents and inadequate communication to the family about a fall.
Addressed to: Dudley Group NHS Trust
AI-generated concerns summaryThe coroner noted Mrs Kaur's long-term addiction to zopiclone and identified concerns with the decision to abruptly discontinue the medication to prevent self-harm.
Addressed to: Black Country NHS Trust; Lodge Road Surgery
AI-generated concerns summaryThe coroner raised concerns regarding excessive vehicle speeds and unsafe pedestrian crossing behaviour on Barrack Road near a school. There is also confusing signage where a cycle lane ends, which could lead to further collisions.
Addressed to: Dorset County Council
AI-generated concerns summaryThe coroner noted that Mr King's medical treatment in Egypt was affected by insurance cover issues, and his family experienced difficulties contacting the British consulate for assistance, highlighting a need for improved communication channels.
Addressed to: Foreign Office
AI-generated concerns summaryThe waiver for boat and snorkelling trips did not inform participants with epilepsy about the dangers of swimming in the sea and did not request their past medical history.
Addressed to: Groupo de Turismo Gaviota S.A; Thomas Cook
AI-generated concerns summaryThe coroner noted ongoing operational shortages and insufficient ambulance resources within NEAS led to significant delays in urgent case responses. Concerns were also raised about indirect patient contact potentially impacting the initial clinical review.
Addressed to: North East Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner identified an insufficient system for collating patients' antibiotic history within the Hospital Trust. They also noted a lack of clear requirements for Trusts to follow existing guidelines on antibiotic history and suggested a need for further Department of Health guidance.
Addressed to: Department for Health; Royal College of Surgeons
AI-generated concerns summaryThe crisis team did not advise Mr. Ireland or his friend that he could present at the emergency department for his mental health crisis, which may have prevented an urgent assessment.
Addressed to: Devon NHS Trust
AI-generated concerns summaryPoor quality nursing notes and observation charts hindered consultants' understanding of patient events. The coroner also identified a lack of checking procedures for verbally prescribed medications, which led to an incorrect drug administration.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryThe report highlights a previous near-fall incident at the location and a lack of response by security guards to an activated fire exit alarm.
Addressed to: Black Country North Fire Safety team; Transport for West Midlands; West Midlands Combined Authority; West Midlands Fire Service; Wolverhampton City Council
AI-generated concerns summaryThe coroner noted the ineffectual steps taken to halt a cycle race after an accident and the absence of formal, effective procedures in national cycling regulations for stopping races in such events.
Addressed to: British Cycling; Cycling Time Trials; League of Veteran Racing Cyclists; Scottish Cycling; The League International; Welsh Cycling