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 that Mrs Smith's family and the care provider's corporate risk function were not informed of her hip fracture's details, limiting investigation and learning. There was no audit of incidents following the departure of the manager responsible for internal reporting, despite documentation allegedly going missing.
Addressed to: Borough Care
AI-generated concerns summaryThe nursing home staff lacked adequate training for Mr Stannard's mental ill health as his physical condition improved, and no suitable home for dual mental and physical health needs was available. Concerns also included incomplete staff records and underutilised IT systems.
Addressed to: Norfolk & Suffolk NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the absence of signage to warn road users about severe gradients and limited visibility on the A593, and questioned the appropriateness of the 60 mph speed limit for this road.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner raised concerns regarding the delay in scheduling an urgent psychiatric review following an indication of suicidal ideation, and the mental health practitioner's unfamiliarity with self-harm protocols and subjective risk assessment methods.
Addressed to: South Staffordshire and Shropshire NHS Trust
AI-generated concerns summaryThe coroner noted inadequacies in patient observations, including insufficient methods to detect deterioration in sedated patients and a lack of required welfare checks for immobile patients. Concerns were raised regarding staff understanding and adherence to the Observation and Engagement Policy.
Addressed to: Coventry and Warwickshire NHS Trust
AI-generated concerns summaryThe coroner noted that an escalation policy between ADS and Pennine Care was not followed, and ADS workers lacked clear guidance and clinical support. There were also concerns regarding the documentation and facilitation of shared care discussions, especially as the GP had not seen the deceased.
Addressed to: ADS
AI-generated concerns summaryThe coroner identified that the deceased was not asked about suicidal ideas or plans on 8/8/17. Additionally, the daughter's concerns were not recorded on 11/8/17, both preventing the implementation of supportive measures.
Addressed to: Oxleas NHS Foundation Trust; Department of Health; The Chief Coroner
AI-generated concerns summaryThe coroner noted a lack of consistency and continuity of care from the Crisis Team due to changing personnel, alongside issues with accurate and prompt record-keeping. Concerns were also raised about the timely escalation of issues to senior staff to ensure appropriate patient management, including potential hospitalisation.
Addressed to: Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified a lack of regular medication reviews and no guidelines to limit medication availability. Additionally, limited information sharing within the Trafford Adult Safeguarding Board hindered awareness of police interactions with Mr Robb and restricted strategic oversight.
Addressed to: Trafford Adult Safeguarding Board; Trafford Clinical Commissioning Group
AI-generated concerns summaryThe report is incomplete and does not contain any specific concerns from the coroner.
Addressed to: Carlton House Rest Home; Compliance Manager
AI-generated concerns summaryThe coroner raised concerns about the lack of a comprehensive written discharge plan from the Priory Hospital, which did not identify the responsible Home Treatment Team or communicate the patient's consent for collateral contacts. There were also gaps in proactive liaison and information sharing between the hospital and the Home …
Addressed to: Oxleas NHS Trust; Department of Health; The Care Quality Commission; The Chief Coroner; Priory Hospital
AI-generated concerns summaryThe coroner noted a lack of evaluation and assessment documentation for Mrs. Postill after her return on May 2, 2017. There was also poor quality documentation at Tameside Hospital, with insufficient detail regarding clinical decision-making during her second visit.
Addressed to: Sunnyside Care Centre; Tameside General Hospital
AI-generated concerns summaryThe prison's stabilisation wing had insufficient capacity for inmates needing detox and night welfare checks. The method of conducting night welfare checks through a cell door hatch was considered inadequate for ascertaining if a prisoner was breathing or alive.
Addressed to: Care UK; Dorset Health Care University; Home Office
AI-generated concerns summaryThe coroner identified the absence of a form or template for referring prisoners to mental health services, noting that reliance on telephone conversations for this vital information is unreliable. A robust documentary system is required for such referrals.
Addressed to: Bindmans Solicitors; Care UK; Essex Partnership NHS Trust; HM Prisons and Probation Service; Phoenix Futures
AI-generated concerns summaryThe coroner identified a lack of continuity in medical care, gaps in basic nursing care such as unrecorded vital signs, and a failure to recognise and escalate patient deterioration. Concerns were also raised about the qualifications of 'Hospital at Night' site co-ordinators managing out-of-hours medical prioritisation.
Addressed to: Salford Royal Hospital
AI-generated concerns summaryThe coroner noted that emails from the patient to lead consultants were often not viewed or responded to. This led to a lack of communication, and the report suggests a need for national or local guidelines for patient-clinician communication, including emails and phone calls.
Addressed to: Barts Health NHS Trust; Brompton NHS Trust; Secretary of State for Health
AI-generated concerns summaryThe coroner identified insufficient co-ordination in discharge planning from inpatient psychiatric care, including a lack of liaison between professionals and family. Concerns were also raised about the inability to pre-arrange ambulances and the informal nature of risk assessments before executing MHA warrants.
Addressed to: NHS England; Department for Health; Nottingham County Council; Nottingham Police; Nottinghamshire Healthcare NHS Trust; Police and Crime Commissioner, Nottinghamshire; the Home Department; Yorkshire Ambulance Service NHS Trust
Addressed to: Care UK; HMP Pentonville; HM Prisons and Probation Service
AI-generated concerns summaryThe coroner noted a lack of awareness among emergency medicine professionals regarding the risk of respiratory depression when local anaesthetic blocks are administered after opioids. There were no national guidelines for monitoring patients post-procedure to mitigate this risk.
Addressed to: Royal College of Emergency Medicine; Royal College of Surgeons
AI-generated concerns summaryThe coroner noted a lack of clear guidance in Volvo vehicle manuals regarding the safe use of automatic gearboxes during long downhill descents. This insufficient information for drivers could potentially exacerbate brake fade without explicit warnings from the manufacturer.
Addressed to: Volvo Group (UK) Limited