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 noted a disparity in urgent mental health service provision across Greater Manchester, specifically that Trafford's Home Based Treatment Team does not accept direct GP referrals, unlike Manchester's. This meant GPs dealing with urgent mental health issues for Trafford residents out-of-hours had to ask patients to attend A&E.
Addressed to: Trafford Clinical Commissioning Group; Greater Manchester
AI-generated concerns summaryInsufficient staff training for a new IT system led to the premature closing of patient access plans and a lack of review, which placed patients at risk of harm.
Addressed to: Walsall Healthcare NHS Trust (Manor Hospital)
AI-generated concerns summaryThe coroner identified failures in the Emergency Department to correctly assess and diagnose injuries and missed opportunities for earlier specialist review. There were also poor systems for providing a collar, communication issues, and delays in obtaining a CT scan.
Addressed to: Chief Executive, Sandwell Hospital and West Birmingham Hospital NHS Trust
AI-generated concerns summaryThe coroner noted missing formal agreements for independent consultant reviews and undocumented communication/escalation procedures. Concerns were also raised about a single resident medical officer providing 24/7 post-operative care without clear hospital oversight, and the absence of protocols for transferring unwell patients.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified concerns regarding the absence of a safe system of work on site, a widespread practice of employees not wearing seatbelts, and an inadequate system for checking seatbelt compliance.
Addressed to: Rose Builders and Contractors Ltd
AI-generated concerns summaryThe coroner noted concerns regarding the system for requesting X-rays at Park & St Francis Surgeries, leading to delays, and an IT issue at the Trust where an emergency department X-ray request was incorrectly registered as an inpatient referral.
Addressed to: Hampshire NHS Trust; Park & Francis Surgery
AI-generated concerns summaryThe coroner raised concerns regarding the four-hour delay in patient transport delivering the patient home and whether his deteriorating condition could have been identified during this time, or if an option existed for immediate return to hospital.
Addressed to: Staffordshire Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted fragmented care and insufficient consultation between clinicians managing the attacker, alongside a failure to share crucial background information. This led to warning signs of impending violence being unrecognised and recommendations for Mental Health Act assessments not being acted upon.
Addressed to: Greater Manchester Mental Health NHS Trust
AI-generated concerns summaryThe coroner identified gaps in the clarity and consolidation of information provided by hospital staff when reporting AWOL patients, and noted a discernible difference in police response to high-risk informal patients versus those detained under the Mental Health Act.
Addressed to: Sussex Partnership NHS Trust; Sussex Police
AI-generated concerns summaryThe coroner identifies inadequate risk assessment and supervision for open water school trips, insufficient swimming education to prepare children for cold, open waters, and a lack of robust pre-trip swimming ability assessment.
Addressed to: Department for Education
AI-generated concerns summaryNo specific concerns were detailed in the provided text.
Addressed to: Brighton and Sussex University Hospitals; NHS England; CCG, Eastbourne; East Sussex Health Care NHS Trust; SECAMB
AI-generated concerns summaryThe coroner is concerned that medical staff may lack access to urgent specialist advice when faced with unfamiliar conditions, potentially leading to families needing to educate staff about their condition's implications.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding measures to ensure patients with head injuries, especially those on anti-coagulant medication, undergo CT scanning in accordance with NICE guidelines, particularly where there are service issues with on-site CT scanners.
Addressed to: Manchester University NHS Trust
AI-generated concerns summaryThe care home placement was inappropriate for the resident's complex needs, with inadequate falls and pressure sore prevention policies. Staff did not recognise deterioration, seek timely medical assistance, or properly manage medication and care records.
Addressed to: Community Disability Nurse; Independent Futures, Southwinds Care Home
AI-generated concerns summaryThe coroner identified a lack of internal investigation or serious incident review by the Probation Service following the death of a released prisoner, along with procedural issues for referring prisoners back to the Parole Board after a licence breach.
Addressed to: HM Inspectorate of Probation
AI-generated concerns summaryThe coroner noted the unavailability of previous medical records, the absence of a rapid-tilt trolley for anaesthetisation, and issues with equipment, including a faulty bronchoscope. Procedural concerns also included the non-use of cricoid pressure and NG tubes.
Addressed to: University Hospitals of North Midlands
AI-generated concerns summaryThe coroner identified two concerns: delays in emergency service calls due to prison officers not strictly following the Code Blue/Red system, and an insufficient number of passive dogs to control Novel Psychoactive Substances in prisons.
Addressed to: HMP Wormwood Scrubs
AI-generated concerns summaryThe coroner noted that the deceased had not commenced an intensive Probation treatment programme, which was part of their sentence, due to high demand and significant backlogs in allocating places.
Addressed to: National Probation Service
AI-generated concerns summaryThe coroner identified communication gaps between GP and mental health services, disparate healthcare record systems hindering information sharing, and a lack of clarity regarding appropriate crisis pathways and team roles for patients in mental health crisis.
Addressed to: Cornwall Health; Cornwall NHS Trust; NHS England
AI-generated concerns summaryThe coroner noted insufficient communication between the nursing home and GP surgery, leading to a lack of required lithium blood tests. Additionally, a consultant's advice on medication reduction was not seen by the GP.
Addressed to: NHS England