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 failures in contacting the ambulance service, recording the request, and correctly grading an emergency call. There were also insufficient efforts to search for and check on Mr. Banks' wellbeing at the scene.
Addressed to: Devon and Cornwall Police Headquarters
AI-generated concerns summaryThe discharge process did not include cautionary advice on analgesic use, and treating clinicians did not receive alerts from the haematology laboratory for abnormal ALT and toxic paracetamol levels.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryInsufficient staffing, unclear advanced nurse practitioner roles, and inadequate nursing training in respiratory distress and escalation of concerns were identified in the NICU. The coroner also noted inconsistent patient observation records and a lack of clear transfer and handover policies.
Addressed to: Isle Of Wight NHS Trust
AI-generated concerns summaryThe coroner identifies gaps in communication and transition between CAMHS and adult mental health services for 16-18 year olds. This includes issues with out-of-hours provision, placement in adult crisis houses, and returning them to unsupervised supported living.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the accuracy and completeness of records for patient care, including fluid intake, diet, nutrition, and hospital discharge arrangements, which could compromise staff's ability to react to unfolding events.
Addressed to: Fremantle Trust
AI-generated concerns summaryThe coroner noted the absence of guidance, policy, and risk assessments concerning in-store bicycle riding and helmet use, along with no designated safe cycling area. Concerns were also raised about the application of best practice for accident reporting.
Addressed to: Halfords Group PLC
AI-generated concerns summaryEmergency responders did not seek medical assistance for a patient with a pelvic fracture that led to internal haemorrhage, contrary to good practice. A subsequent investigation was flawed, failing to address inaccuracies in a risk assessment checklist and a responder's understanding of their signature.
Addressed to: Care Quality Commission; Department for Community and Local Government; Department of Health and Social Care; Eldercare; Wigan Council
AI-generated concerns summaryThe coroner identified gaps in assessing mental capacity, in the completion and handover of investigations from A&E to AMU, and in conducting neurological and general observations. The report also noted issues with staffing levels and competence on the ward.
Addressed to: Care Quality Commission; Manchester Clinical Commissioning Group; University of South Manchester Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient recording and monitoring of carriageway deterioration by highway inspectors. Additionally, concerns were raised that a new highway management procedure, by redefining the 40mm defect threshold to an 'investigation level', could increase risks, especially for cyclists.
Addressed to: Bury Metropolitan Borough Council; Department for Transport
AI-generated concerns summaryThe coroner noted a lack of local guidance in most South West NHS Trusts for gallstone pancreatitis surgery. Urgent cholecystectomy was not prioritised due to competing demands, despite doctors being aware of international recommendations.
Addressed to: N.I.C.E
AI-generated concerns summaryThe drug administration chart does not clearly differentiate between oral and intravenous paracetamol, nor does it include a patient's weight reference for intravenous administration, which is needed to modify dosage.
Addressed to: Mid Yorkshire NHS Trust
AI-generated concerns summaryThe coroner identified a lack of regulation and safety standards for the design, manufacture, and installation of stone fireplaces. This includes insufficient quality standards for heavy components and an absence of building control regulations for installation.
Addressed to: Department of Business, Energy and Industrial Strategy; Department of Communities and Local Government
AI-generated concerns summaryThe coroner identified ambiguous discharge information, an unrecorded telephone call giving medical advice, and insufficient documentation or escalation of nurse observations. There was also no formal policy for routine observations in wound review clinics, even with indications of infection.
Addressed to: Wrightington, Wigan and Leigh NHS Trust
Addressed to: HMP Pentonville
AI-generated concerns summaryThe coroner noted severe deterioration of a wooden panel and metal fixings on a building's roof, which contributed to a fatal incident. This was attributed to a lack of maintenance over at least 19 years.
Addressed to: RICS; ROYAL INSTITUE of CHARTERED SURVEYORS (RICS)
AI-generated concerns summaryThe GP surgery lacked a formal, documented protocol to ensure consultant-prescribed repeat medications were added to patient records and checked during subsequent visits. Additionally, the NHS Trust had no protocol for vulnerable patients who self-discharge, particularly regarding follow-up to ensure medication and support.
Addressed to: Grasmere Surgery; Wrightington, Wigan and Leigh NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the criteria for issuing and surrendering driving licenses, noting drivers may not voluntarily surrender them due to independence concerns. A potential conflict of interest for GPs in reporting medical fitness to drive was also highlighted.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner noted differing practices in the use of high-resolution screens for X-ray viewing and a tendency for clinicians to focus on expected findings. Concerns were also raised about the unclear process for escalating cases to consultant level and critical care.
Addressed to: Stepping Hill Hospital
AI-generated concerns summaryThe report highlights limited DVLA mechanisms for medical review of drivers with deteriorating health, potential conflicts for GPs reporting issues, and no verification for required vehicle modifications after changes in health or car.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency
AI-generated concerns summaryThe coroner raised concerns regarding the apparent lack of a robust system to ensure individuals with mental health problems, especially those with psychotic episodes, are seen and receive appropriate care. A patient was discharged from the service with no further efforts made to re-engage him after a missed appointment.
Addressed to: Cwm Taff University Hospital Health Board