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 noted Addcounsel continued charging a patient for visits from a non-medically qualified director while an inpatient, despite no treatment being provided. Concerns were raised that the patient's financial worries were not addressed nor was NHS care access highlighted.
Addressed to: Addcounsel
AI-generated concerns summaryThe coroner noted concerns regarding a policy change to reduce restrictive practices, which led to the removal of plastic bag restrictions following a previous incident where the deceased placed a plastic bag over her head.
Addressed to: Cambian Group; Raglan House
AI-generated concerns summaryThe coroner raised concerns regarding poor visibility for vehicles turning right at a junction due to an incline and queuing traffic. Issues also included uncertainty about right of way and inadequate signage for one of the turning points.
Addressed to: Nottingham County Council
AI-generated concerns summaryThe coroner raised concerns that Ecolab Ultracover sheaths, used for Transoesophageal Echocardiograms (TOEs), may be linked to multiple fatal oesophageal tears. A review of these sheaths is recommended, considering their replacement with Probetection sheaths across all hospitals and Trusts.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner raised concerns about the extreme toxicity of DNP, its increasing popularity among young people as a 'diet drug', and its ready availability online, noting that current legislation does not make its possession, sale, or supply illegal.
Addressed to: Department for Health
AI-generated concerns summaryBritish Cycling does not undertake health assessments or medical screening for young riders on its World Class Programme. A cardiologist indicated such screening can identify cardiac abnormalities in asymptomatic young people.
Addressed to: British Cycling
AI-generated concerns summaryThe coroner noted a lack of clarity among healthcare staff regarding Intelligence Reports, requiring improved communication, criteria, and audit. Further improvements are needed in reducing access to illegal substances, psychosocial service referrals, and record keeping.
Addressed to: Care UK Clinical Services; Essex Partnership University NHS Foundation Trust; Farleys Solicitors LLP; HM Prison and Probation Service; Phoenix Futures
AI-generated concerns summaryThe coroner noted care home staff, lacking formal medical training, made assumptions about the resident's health following falls and disregarded a request for an ambulance. There was also insufficient communication with the GP about the resident's recent health events.
Addressed to: Dairy Lane Care Centre
AI-generated concerns summaryThe coroner raised concerns regarding the failure to escalate and act on a patient's deteriorating condition, the lack of clinical review and risk reduction during transfer, and the trust's subsequent lack of internal investigation or learning opportunities.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted inadequate application of staff training at W-CDAS, resulting in poor risk assessment for vulnerable patients. Additionally, improved communication between inpatient and community services and a consistent set of clinical records were identified as necessary.
Addressed to: Wandsworth Consortium Drug and Alcohol Services
AI-generated concerns summaryThe coroner was concerned by a delay in a necessary CT-guided fluid drainage procedure due to insufficient staff and inadequate escalation. There were also no ERCP procedures available for six days due to a consultant's annual leave, causing further delays.
Addressed to: Tameside General Hospital NHS Trust
AI-generated concerns summaryThe coroner noted that a nurse's observation of neck pain was not escalated to a doctor, potentially delaying diagnosis of a cervical spine fracture and risking adverse outcomes if similar communication gaps recur.
Addressed to: CWM Taff University Board
AI-generated concerns summaryThe care coordinator, central to the patient's new treatment strategy, did not see her, undermining the approach. Concerns were also raised about the difficulty contacting the care team during a crisis due to a single, inadequate phone line.
Addressed to: Worcester Health and care Trust
AI-generated concerns summaryThe coroner noted difficulties in cross-border care provision where a patient's GP and social care commissioning are in different counties, leading to an inability to access therapeutic services.
Addressed to: Gloucestershire Clinical Group; Herefordshire Clinical Commission Group
AI-generated concerns summaryThe coroner identified a need to stop the practice of allowing open-ended urinary catheters to drain freely, establish proper procedures for catheter management with specialist advice, and ensure all staff are adequately trained in their care.
Addressed to: Milestones Trust
AI-generated concerns summaryThe coroner noted the driver likely had undiagnosed dementia before the incident. Concerns were raised that the current licence renewal scheme for over-70s relies on self-reporting and lacks mandatory objective testing for fitness to drive.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner identified limitations with the analogue Careline system that can impede emergency services access and prevent other residents from making calls when the line is in use. Concerns were also raised about insufficient labelling of keys in the safe, leading to delays for emergency services.
Addressed to: First Port Retirement Property Services Limited
AI-generated concerns summaryThe coroner noted a lack of understanding of capnography readings during CPR, insufficient coordination and situational awareness, and limited experience among senior staff in managing crisis situations.
Addressed to: Department for Health; North Cumbria University Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a lack of established protocols to ensure patient-owned medical equipment, such as CPAP machines, remains with the patient and is immediately available for use following transfer between hospital wards.
Addressed to: Salford Royal NHS Trust
AI-generated concerns summaryThe provided text indicates that specific concerns were appended to the report but does not detail them.
Addressed to: Cafcass; Department for Housing, Communities and Local Government; London Borough of Sutton; Services for Children; Sutton and Merton Community Services; Sutton Local Safeguarding Children’s Board; Children’s Guardian