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 identified that the nurse undertaking initial health screening lacked access to pertinent prisoner documentation, including the Prisoner Escort Report and digital medical records. Concerns were also raised about the recording of such documentation and the sufficiency of ACCT training for probation staff.
Addressed to: HM Prison and Probation Services
AI-generated concerns summaryThe coroner noted significant gaps in neurological observations, which were not performed every 30 minutes as required, and an elevated NEWS observation was not acted upon promptly. There was also insufficient management to ensure nurses carried out checks.
Addressed to: ABMU Health Board
AI-generated concerns summaryThe coroner noted that adult services in other local authorities could benefit from lessons learned from shortcomings identified and addressed by Hampshire County Council following this death.
Addressed to: Adult Social Services
AI-generated concerns summaryThere is uncertainty regarding the necessity of a senior paediatrician review before discharging a child when parents request a second opinion. The report also identifies insufficient clear criteria for learning lessons from re-presentations.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted insufficient face-to-face reviews and inadequate documentation for long-term prescriptions of strong and unlicensed medications. Doctors prescribed without sufficient knowledge of the patient's health, contrary to GMC guidance.
Addressed to: Fitzalan Medical Group; West Sussex Clinical Commissioning Group
AI-generated concerns summaryThe coroner questioned Whirlpool's risk assessment processes for fire hazards from a door switch assembly and their reliance on internal advice over reported incidents. There were also concerns about insufficient public awareness regarding the risk of spontaneous combustion fires.
Addressed to: Whirlpool (UK) Appliances
AI-generated concerns summaryThe coroner was not confident in Whirlpool's risk assessment processes to fully appreciate fire risk, noting the company's reluctance to rely on reported fire data. Concerns were also raised about insufficient public awareness regarding the magnitude of spontaneous combustion fire risks.
Addressed to: Whirlpool (UK) Appliances
AI-generated concerns summaryThe coroner identified the ease of acquiring large amounts of prescription-only medication online and noted insufficient clarity on actions being taken to address this, posing a significant risk of future deaths.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe coroner identified inconsistent handover processes across different hospital wards and a lack of routine senior doctor review for complex patients admitted over weekends. Concerns also included insufficient leadership during a patient's crisis period and inadequate medical record-keeping.
Addressed to: Worcestershire Acute Hospital Trust
AI-generated concerns summaryThe coroner identified deficiencies in the system for controlled drug management. Concerns also included a lack of escalation in the observation policy for patients needing review before discharge, and a witness's non-acceptance of lessons from the investigation.
Addressed to: Care Quality Commission; Central Manchester University Hospitals; NHS England
AI-generated concerns summaryConcerns were raised regarding the administration of medications, with particular note on the documentation and dispensation of palliative medications.
Addressed to: Barchester Homes
AI-generated concerns summaryThe coroner noted a significant delay in the Serious Incident Analysis report, dated 18/3/2015, being received by their office, with its delivery occurring only in the last week.
Addressed to: United Lincolnshire Hospital
AI-generated concerns summaryDuring an international patient transfer, there was inadequate handover and insufficient documentation, compounded by language barriers. UK clinicians received incomplete, untranslated medical information from Italy, leading to delays and uncertainty in the patient's treatment.
Addressed to: Insure and Co
AI-generated concerns summaryThe coroner noted the absence of a system for NHS Digital to communicate clinical urgency in community pharmacy prescriptions, and Cegedim's software has misleading information about an urgency flagging feature. The report also notes Wells Pharmacy's urgent prescription management trial may not be permanently adopted.
Addressed to: Managing Director of Cegedim; NHS Digital; Wells Pharmacy
AI-generated concerns summaryThe coroner noted that an agency nurse's unfamiliarity with policy led to insufficient referral of a pressure sore and delayed awareness by clinicians. Additionally, dietician's nutritional advice was not implemented, and ward understaffing affected patient care.
Addressed to: St Peter’s Hospital
AI-generated concerns summaryThe coroner noted the absence of specific guidance from the GPhC for pharmacies on 'red flag' systems for patients with similar identifying details. Concerns were also raised about the lack of clear guidance on the chain of custody for Controlled Drugs, leading to inconsistent local practices.
Addressed to: General Pharmaceutical Council
AI-generated concerns summaryThe coroner noted deficiencies in the availability and review of mental health records, inadequate detail in risk assessments, and staff misunderstanding of suicide risk indicators. There were also concerns regarding disjointed care coordination between providers.
Addressed to: Camden & Islington NHS Trust; One Housing Group
AI-generated concerns summaryThe coroner raised concerns about prescribing medication without consulting GP records and poor recording. A serious drug interaction was not appreciated, and family input was not adequately noted or acted upon, causing diagnostic delays.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryThe coroner noted an ineffective pathway for communicating information directly to the RDaSH Crisis Team.
Addressed to: Yorkshire Ambulance Service
AI-generated concerns summaryThe coroner noted unclear policy on patient supervision in toilets and issues with inter-hospital transfer of radiology images. Concerns were also raised regarding Royal Blackburn Hospital's refusal to perform specific X-rays, causing treatment delays.
Addressed to: East Lancashire Hospitals NHS Trust