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 breaches in Information Governance protocols, identifying that clinicians could access and alter patient medical records using colleagues' log-ins, and that these changes were not visible to treating clinicians without an IT audit.
Addressed to: Care Quality Commission; Isle of Wight NHS Trust; St Mary’s Hospital
AI-generated concerns summaryMultiple care and service delivery problems were identified, alongside a lack of understanding and empathy from the social worker and community psychiatric nurse. There is a need for significant improvement in staff training regarding risk assessment and the escalation of concerns for psychiatric assessment within the CMHT.
Addressed to: Betsi Cadwaladr University Health Board; Wrexham County Council; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted a lack of clear processes for in-patient transfers, time-specific care plans, and consistent risk assessment terminology. Insufficient guidance for staff communicating with young persons and managing out-of-area psychiatric care for children was also identified.
Addressed to: Avon & Wiltshire Mental Health Partnership NHS Trust; Dorset Healthcare University NHS Trust; NHS England
AI-generated concerns summaryThe coroner noted Heart of England NHS Foundation Trust lacked clear guidelines for high-risk fracture management, continuity of care, and adequate discharge planning. St Giles nursing home also lacked a care plan for plaster cast management, failed to check for infection, and had no further staff training in this area.
Addressed to: Heart of England NHS Trust; St Giles Care Home
AI-generated concerns summaryThe coroner raised concerns regarding the adequacy of intelligence processes, including reporting, analysis, training, and audit. There were also issues with an internal report on these matters not being shared with appropriate staff.
Addressed to: HMP Long Lartin
AI-generated concerns summaryThe provided text indicates a risk of future deaths but does not detail specific concerns identified by the coroner.
Addressed to: Brighton and Sussex University Hospitals NHS Trust; St George’s University Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about insufficient revision of the mobility care plan despite documented deterioration, a lack of monthly mobility reviews, and the failure to contact a GP or ambulance when the patient was unable to weight-bear.
Addressed to: Rosewood Lodge Nursing Home
AI-generated concerns summaryThe coroner noted a lack of a single individual taking overall responsibility for Mr Goodrum's care. A recommended action to allocate a Lead Care Professional or Care Co-Ordinator was not implemented, and alternative team-based approaches were found to be less effective.
Addressed to: Norfolk and Suffolk NHS Trust
AI-generated concerns summaryThe coroner noted an inconsistent approach by staff to conducting and recording enhanced observations for mental health patients at risk of self-harm, with no training or written guidelines provided, and precise observation times not routinely recorded.
Addressed to: Welsh Government; Ludlow Street Healthcare
AI-generated concerns summaryThe coroner noted the absence of clear and robust policies for falls prevention and management at the care home, and questioned staff understanding and consistent application of existing procedures.
Addressed to: Coxbench Hall Residential Home
AI-generated concerns summaryJunior doctors did not fully complete mandatory VTE risk assessments, and a consultant's assessment did not identify this issue nor was it documented. There was also a delay exceeding 24 hours in providing thromboprophylaxis.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryThe coroner noted insufficient consideration of the totality of prescribed medications and their potential synergistic effects, particularly for drugs affecting the central nervous system and respiration, which combined to cause a drug poisoning death.
Addressed to: Hull and East Riding NHS Trust, The Local Medical Committee; NHS England
AI-generated concerns summaryInsufficient escalation of carers' concerns and poor understanding of incident reporting for illness led to delays in resident care. Staff did not directly manage medical issues or promptly call emergency services, causing critical delays in hospital transfers.
Addressed to: Beech Cliffe Grange Care Homes
AI-generated concerns summaryThe coroner noted insufficient oversight by consultant radiologists for ultrasonography reports and a potential lack of awareness among general practitioners regarding the implications of supra-renal aortic aneurysm findings for thoracic aortic aneurysms.
Addressed to: NHS England; Royal College of General Practitioners; Society of Radiographers
AI-generated concerns summaryThe coroner identified incomplete and outdated risk assessments, poor nursing communication, and gaps in documentation by both medical and nursing staff. Concerns also included incorrect NEWS score calculations, a lack of escalation when an on-call doctor did not attend, and non-adherence to Trust policies.
Addressed to: Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the absence of written guidelines for dismantling cantilevered scaffolds and raised concerns about the lack of a separate Risk Assessment Method Statement (RAMS) specifically for scaffold dismantlement.
Addressed to: Health and Safety Executive
AI-generated concerns summaryInsufficient surgical cover at County Hospital was noted, with remote advice not a substitute for a physical presence. Concerns were also raised about inconsistencies in duty policies and equipment between County Hospital and RSUH within the same Trust.
Addressed to: University Hospitals North Midlands NHS Trust
AI-generated concerns summaryThe coroner identified delays in ordering Debrisoft for wound management and poor communication, alongside confusing systems, regarding its procurement process and overall responsibility.
Addressed to: Dudley Group NHS Trust
AI-generated concerns summaryThe coroner noted insufficient training for North Wales police officers in identifying mental health issues, and that 'Concern for Safety' incidents were closed without recorded resolution of the person's welfare.
Addressed to: North Wales Police
AI-generated concerns summaryThe Wallows Lane level crossing is unprotected, lacks warnings for approaching trains, and relies on user vigilance, creating a danger of confusion when multiple trains pass, compounded by obscured views from double-height carriages.
Addressed to: HM Inspector of Railways; Network Rail; Office of Rail and Road (ORR); Walsall Local Authority