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 summaryHospital staff delayed police notification of a potentially suspicious death due to confusion over procedures. Concerns were also raised about insufficient basic incident details, such as the address, in ambulance service handovers, particularly from private providers.
Addressed to: Royal Hampshire County Hospital; South Central Ambulance Service NHS Trust
AI-generated concerns summaryConcerns were raised regarding a seven-month delay in repairing a category 2 pothole and the repair of the wrong pothole. The local authority lacked systems to track contractor work orders and conduct formal audits of completed repairs.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner raises concerns about the lack of clear communication to patients and their carers regarding follow-up mental health appointments after discharge. There is no formal policy or protocol requiring notification or written confirmation of these arrangements, increasing the risk of missed appointments and lost opportunities for patient review.
Addressed to: Northern Health and Social Care Trust
AI-generated concerns summaryThe coroner identified that a clinician was unaware of the patient's ongoing delusions at discharge, leading to a missed opportunity for family communication about relapse signs and no formal mental health aftercare referral.
Addressed to: NHS Lothian Scotland
AI-generated concerns summaryThe patient was discharged from hospital while still experiencing delusions, with the clinician unaware of the family's observations. There was insufficient communication with the family about relapse symptoms and no formal referral or aftercare arranged with mental health services post-discharge.
Addressed to: NHS Lothian Scotland
AI-generated concerns summaryThe Chesterfield Royal Hospital did not promptly inform the nursing home or GP of a patient's cervical spinal fracture or necessary care measures, with formal confirmation only provided after nursing home enquiries. This communication gap had the potential to adversely affect wellbeing.
Addressed to: Ashgate House Nursing Home; Chesterfield Royal Hospital
AI-generated concerns summaryConcerns were raised that care workers leaving visits early could lead to insufficient interaction with service users, potentially overlooking risks to their welfare.
Addressed to: Safehands Ltd
AI-generated concerns summaryThe coroner raised concerns regarding the manufacturer's understanding of flame extension risks associated with Glade Automatic Air Freshener Spray. Warnings on the packaging and aerosol were deemed insufficiently prominent, with no warnings on the device itself after the box is discarded.
Addressed to: SC Johnson and Son
AI-generated concerns summaryThe coroner noted family contentions regarding the trust's adherence to NICE guidelines and its own policies for cancer screening, referrals, diagnosis, and treatment.
Addressed to: Basildon and Thurrock University Hospital Trust
AI-generated concerns summaryThe coroner noted incorrect triaging of a call where evidence of vomiting and drowsiness should have led to a faster response, and insufficient resources resulted in average response times of 29 minutes.
Addressed to: West Midlands Ambulance Service
AI-generated concerns summaryThe coroner noted that the urgent referral process was slow and cumbersome, being made by post. Additionally, there was a significant delay in securing a maxillofacial unit appointment, with the rescheduled date nearly seven weeks after the initial referral.
Addressed to: Homerton University Hospital NHS Trust; Kindandental
AI-generated concerns summaryConcerns were raised about pedestrian safety at a Swindon junction, identifying inadequate clear views for pedestrians using the crossing and insufficient time to cross due to a short all-red light phase, compounded by a lack of pedestrian signals.
Addressed to: Department for Transport; Swindon Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding police call handling and record-keeping, and the sufficiency of guidance for call handlers on immediate risk assessment and for mental health assessors on family input. The report also notes insufficient information sharing between agencies and a lack of understanding among mental health clinicians regarding the …
Addressed to: Essex Partnership University NHS Foundation Trust; Essex Community Rehabilitation Company; Essex Police
AI-generated concerns summaryInadequate recording of Ms Williams' care plan led to missed reviews and delayed medical appointments. Additionally, the care coordinator did not address family concerns and made undeclared retrospective entries in medical records.
Addressed to: East London NHS Trust
AI-generated concerns summaryThe coroner noted gaps in the care co-ordinator's mandatory reviews and record-keeping for Ms Bozdag, including unrecorded discussions and failure to update her drug card, resulting in under-medication.
Addressed to: East London NHS Trust
AI-generated concerns summaryThe coroner noted delays in implementing strategies, identified in an earlier Root Cause Analysis, to address a missed opportunity concerning a reducing haemoglobin trend. The report seeks confirmation of when a solution for flagging significant haemoglobin drops will be implemented by the Trust.
Addressed to: Wirral University Hospital Trust
AI-generated concerns summaryThe surgery lacked adequate systems for processing and recording notifications from external healthcare professionals, leading to a General Practitioner being unaware of a treatment plan and insufficient communication with the patient.
Addressed to: Heaton Medical Centre
AI-generated concerns summaryThe emergency department lacked a system to check patients' recent presentations or admissions, which meant previous relevant records and investigation results were not routinely accessed.
Addressed to: Comish Way Group Practise; UHSM
AI-generated concerns summaryThe coroner noted a lack of proactive risk assessment and understanding by Social Services regarding the deceased's fire risks. Concerns were raised about the absence of processes for fire risk identification, referrals to the fire service, and installation of appropriate fire suppression systems and assistive technology in properties by the …
Addressed to: Great Places Housing Association; Director of Housing; Department for Adult Social Services; NHS Manchester Clinical Commissioning Group
AI-generated concerns summaryThere was a delay in contacting the Consultant Spinal Surgeon, an omission in checking haemoglobin levels, and internal haemorrhage was not considered a cause for the patient's instability.
Addressed to: Department of Health and Social Care; Kettering General Hospital; Nursing and Midwifery Council; Royal College of Anaesthetists; Royal College of Surgeons; Woodlands Hospital