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 raised concerns about information sharing between healthcare and prison staff, the accessibility of historical risk information, and the adequate recording of changes in mood or behaviour on prison wings to inform risk assessments.
Addressed to: HMP Highpoint; HM Prison and Probation Service; NHS England
AI-generated concerns summaryThe coroner identified gaps in risk assessment for prisoners during the patrol state when an ACCT is opened, noting a lack of mental health input. Further concerns included the unhelpful NOMIS layout regarding past ACCTs and the absence of wing transfer documentation for risk factors.
Addressed to: HMP Bedford; HM Prison and Probation Service
AI-generated concerns summaryNursing staff did not appreciate a doctor's entry regarding a rotating right leg, which was then not factored into the care plan. This led to a hip dislocation remaining unrecognised for seven days during a hospital stay, raising concerns about patient monitoring and staff consideration of medical records.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe Telecare service lacked a protocol for informing emergency contacts, allowed unsupervised trainee operators, and provided insufficient structured information to assess service users after alarm activation.
Addressed to: CSS Telecare Service; Elmbridge and Ewell Borough Council; Tandridge District Council
AI-generated concerns summaryCare plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Addressed to: ABMU Health Board
AI-generated concerns summaryConcerns were raised regarding Sofia's initial rejection for CAMHS referral and a significant delay in accessing CBT. The care co-ordinator did not obtain urgent psychiatric input as per guidance, and Sofia's care plan lacked sufficient detail to safeguard her.
Addressed to: CAMHS; NHS Somerset Clinical Commissioning Group; Somerset County Council
AI-generated concerns summaryThe coroner noted a lack of formal investigation into Mr Spencer's serious injury, which reduced the potential for learning and improving safety for other residents, despite general improvements to the facility's falls policy.
Addressed to: Lakes Care Centre
AI-generated concerns summaryConcerns included insufficient consultant involvement and documentation in patient care, discharge by a non-involved nurse practitioner, and inadequate safety netting. The coroner also noted the omission of heparin for a suspected DVT/PE and a lack of effective post-death scrutiny of the unit.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified reliability issues with Rambleguard fall mats, including activation failures and signal delays potentially due to WiFi interference. Staff also lacked interim guidance on managing these operational problems.
Addressed to: Department of Health and Social Care; Rambleguard Ltd; Royal Bolton Hospital
AI-generated concerns summaryPre-fight medical checks were incomplete for boxers, including the deceased's opponent, and medics did not identify this or inform the referee. During the fight, medics did not assess the opponent's fitness after he vomited, relying on the non-medically qualified referee.
Addressed to: Lifeshield Medical Services Limited
AI-generated concerns summaryThe coroner noted insufficient staff training on hoist use and a lack of proper record-keeping regarding the events leading to the death.
Addressed to: Grange Care Home
AI-generated concerns summaryCare and risk assessments did not fully address risks from doors left open, the type of stair-gate, and the locking mechanism. There was also unclear responsibility for ensuring environmental safety measures at the property.
Addressed to: Cardiff City Council; Medical Officer Welsh Government
AI-generated concerns summaryThere was no agreed or consistent policy for managing service users who are unresponsive or cannot be found, and separate guidelines from the local authority and care agency had not been communicated to each other.
Addressed to: London Borough of Sutton
AI-generated concerns summaryThe coroner noted very poor quality medical record keeping and frequent instances where daily nursing and tri-weekly GP medical checks in segregation were either not recorded or did not take place.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified unclear criteria and inconsistent applications for 1:1 care funding at Advinia Healthcare. Concerns also include lengthy wait times for urgent assessments from London Borough of Hounslow and insufficient interim safety measures for high-risk residents.
Addressed to: Advinia Healthcare Ltd; London Borough of Hounslow
AI-generated concerns summaryThe report highlights significant GP shortages, leading to unmanageable workloads, reduced patient access to timely appointments, and a lack of continuity of care. Concerns were also noted regarding the adequacy of GP training and increased thresholds for specialist neurodevelopmental services.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryDespite a previous death in similar circumstances, the coroner noted a lack of adequate warning notices, fencing, or other appropriate measures to mitigate the risks of swimming in the lake.
Addressed to: Parkhill Group of Companies; Walsall Metropolitan Borough
AI-generated concerns summaryThe coroner raised concerns that the 'Stay Put' policy and independent fire alarm systems at Honiton Oaks did not provide adequate external monitoring for individual flats, especially for residents with mobility problems who might struggle to escape during a fire.
Addressed to: Peak Valley Housing Association; Hub
AI-generated concerns summaryThe coroner noted a missed opportunity by a Radiologist to assess a scan, which might have led to further investigation of a mass. There was also a failure to identify a fracture from an x-ray, preventing timely awareness by the patient and family.
Addressed to: Walsall Manor Hospital Trust
AI-generated concerns summaryThe coroner noted concerns regarding an uncontrolled pedestrian crossing point on the A44g dual carriageway, citing its location on a bend, obscured visibility, and the change in speed limit nearby. The crossing is adjacent to a bus stop, care home, and housing estate.
Addressed to: Highways England