Browse 6,458 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 the continuing availability and use of psychoactive substances at HMP Berwyn, despite ongoing initiatives, posing significant risks to the health of prisoners and the potential for future deaths.
Addressed to: Ministry of Justice c/o Government Legal Department, London; Governor, HMP Berwyn
AI-generated concerns summaryAn Assessment, Care in Custody Teamwork process was not initiated following a serious self-harm incident, and there was insufficient evidence of officers' ACCT training or awareness. Keyworker sessions were also not carried out as required, with staff unaware of the expected frequency.
Addressed to: [REDACTED] HMP Garth
AI-generated concerns summaryPPG Healthcare provided insufficient psychologist resources at HMP Garth, limiting services to victims of sexual assault with long waiting lists. There was no decision to fill these resource gaps with locum cover, despite them existing for six months.
Addressed to: [REDACTED], Medical Director, Practice Plus Group
AI-generated concerns summaryThe coroner identified issues with unclear wound care plans and communication from the acute hospital to the care home. Additionally, the care home lacked an escalation policy for managing residents with unclear care requirements on arrival.
Addressed to: Bamford Grange Care Home; Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted an unclear overlap between 'inpatient falls during this admission' and 'previous falls' factors in the Trust's Close Observation Risk Assessment. This ambiguity risks incorrect scoring, leading to insufficient patient observation and increased falls.
Addressed to: Chief Medical Officer for North West Anglia Foundation Trust
AI-generated concerns summaryThe emergency department continues to hold patients requiring ward-based care without an increase in bed space, raising concerns about potential delays in emergency treatment and the circumstances of Mrs. Ward's death being repeated.
Addressed to: Chief Executive – Hull Royal Infirmary
AI-generated concerns summaryThe coroner noted shortcomings in the dissemination of policy and practice changes pertaining to clinical care, specifically regarding the testing of individuals designated as "Covid contacts." Confusion around this policy change persisted even at the time of the inquest.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need for greater awareness and specific clinical guidance for clinicians regarding the increased risks of diagnostic colonoscopies in patients over 80.
Addressed to: President of the British Society of Gastroenterology
AI-generated concerns summaryThe coroner identified a lack of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent practice and insufficient discussion of maternal death risks with women. The report also noted gaps in training standards for community midwives and limited national data collection on home birth outcomes.
Addressed to: [REDACTED], Chief Executive of the Royal College of Midwives, [REDACTED], Chief Executive of the Nursing and Midwifery Council, [REDACTED], Chief Executive of the Royal College of Obstetrics, [REDACTED], Chief Executive of National Institute for Clinical Excellence, [REDACTED], Chief Executive of NHS England; [REDACTED], Secretary of State for Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of age restrictions and inadequate warnings on certain butane/propane aerosol products, alongside concerns about social media platforms' responsibility for harmful content and the appropriateness of their age restrictions.
Addressed to: British Aerosol Manufacturers Association; Department for Business and Trade; Department for Culture, Media and Sport; Department for Science, Innovation and Technology
AI-generated concerns summaryThe coroner notes the need for patients to be transferred to hospital without delay following two unsuccessful attempts to insert a replacement catheter.
Addressed to: High Meadows Care Home
AI-generated concerns summaryThe coroner identified that support staff misunderstood observation protocols and failed to record therapeutic engagement, indicating a training deficit. Concerns were also raised about the inadequacy of EPUT's quality assurance and auditing processes for observations, noting a lack of robust audit tools and mandatory fields in electronic records.
Addressed to: Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that the care home's use of a misleading name contributed to a GP not visiting for a face-to-face assessment. Concerns were also raised about staff training gaps regarding escalation for urgent clinical input and understanding basic patient observations.
Addressed to: Riversdale Care Home
AI-generated concerns summaryThe coroner identified that a GP misunderstood the patient's care home setting, misread critical oxygen saturation levels, and did not adequately review available medical history, leading to no face-to-face clinical assessment.
Addressed to: Marine Lake Medical Practice
AI-generated concerns summaryThe coroner noted a lack of joint agency working and policy on Mental Capacity Act and Mental Health Act assessments, leading to a misunderstanding between service providers regarding their roles and referral processes, compounded by insufficient training.
Addressed to: East Midlands Ambulance Service; Nottingham Healthcare NHS Foundation Trust; Royal College of General Practitioners
AI-generated concerns summaryThe coroner noted a CAMHS referral was closed due to missing contact numbers without further enquiries being made to obtain the information. There are concerns that this lack of effort to progress referrals could risk future deaths.
Addressed to: BCUHB
AI-generated concerns summaryThe coroner raises concerns that heart monitors in other hospital trusts may not re-alert staff if a lead remains disconnected after an initial acknowledgment, creating a risk that cardiac events could go undetected. This deficiency means patients may not be appropriately monitored until equipment is reconfigured and staff are trained.
Addressed to: Department of Health and Social Care; Philips Electronics UK Ltd; NHS England
AI-generated concerns summaryThe coroner raised concerns about insufficient joint agency policy and inadequate local procedures for managing foreign body insertions across health trusts. Clarity on specialised services for personality disorder patients was also lacking after NHCT's dedicated hub disbanded.
Addressed to: Department of Health and Social Care; Nottingham Healthcare NHS Foundation Trust; Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner expressed concern over the continued reliance on A&E departments for individuals in mental health crisis, noting these environments are unsuitable and pose security risks, stemming from a lack of dedicated mental health placements and insufficient investment from commissioners.
Addressed to: Department of Health and Social Care; NHS England & NHS Improvement
AI-generated concerns summaryBooker in Wimbledon, and potentially more widely, sold bulk medicinal products to a customer not authorised to supply them to the public, without conducting required status checks. This raises concerns about the risk of future deaths from the sale of large quantities of medicines to unauthorised individuals.
Addressed to: Brooker Group Limited