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 noted insufficient suicide risk assessment, no comprehensive care plan, and ineffective transfer of care prior to discharge from psychiatric services. Concerns also included delayed urgent assessments and medication recommendations without a psychiatrist's review.
Addressed to: North NHS Trust
AI-generated concerns summaryThe coroner noted an over eight-hour ambulance delay for an elderly patient, primarily due to insufficient ambulance resources and extensive patient handover delays at hospital Accident and Emergency departments. There were also concerns regarding the initial 999 triage process, which did not promptly escalate the urgency of the case.
Addressed to: ABMU Health Board; Welsh Ambulance Trust
AI-generated concerns summaryThe coroner noted delays in identifying high potassium due to blood gas results being separated from records, and a drug error occurred with insulin prescribing for hyperkalaemia, for which there had been no Trust-wide review of the risks.
Addressed to: Heart of England NHS Trust
AI-generated concerns summaryThe coroner notes that an installer's practice of only range testing community alarms in regularly used areas means many existing alarms may not function throughout clients' homes. This raises concerns for service-users whose alarms were fitted before new comprehensive testing procedures were introduced.
Addressed to: Elmbridge Borough Council
AI-generated concerns summaryThe coroner notes that Acute Medical Wards and Mental Health Services are geographically and operationally separate, making transfers of patients with co-occurring serious mental and physical health problems challenging. Improved integrated working, clear pathways, and shared resources are needed to enhance care.
Addressed to: Mid Yorkshire NHS Trust; South West Yorkshire NHS Trust
AI-generated concerns summaryThe coroner identified that a high fall risk resident did not have a sensor mat due to a policy linking provision to mental capacity, recommending an urgent review of this policy.
Addressed to: Excel Care
AI-generated concerns summaryThe coroner noted that three referrals for mental health assessments for Mr Dunkley were not carried out before his death, and a scheduled assessment was not communicated to him or his unit.
Addressed to: HMP Woddhill
AI-generated concerns summaryThe coroner noted that nurses in the special care unit cover babies during breaks without sufficient prior knowledge, suggesting that shift handovers or break-time handovers should include all babies a nurse might be responsible for.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryThe patient was left unsupervised without staff awareness, and ward C19 was already stretched with high-dependency patients, leading to junior staff feeling pressured to accept the patient despite reservations about capacity.
Addressed to: NHS Foundation Trust; New Cross Hospital
AI-generated concerns summaryA discrepancy was identified between the operating surgeon's assessment that an implanted heart valve was defective and an independent review of the explanted valve which found no defect.
Addressed to: MRHA
AI-generated concerns summaryThe coroner identified a lack of clear procedures for managing and monitoring patients who seek to obtain more medication than prescribed, and for exploring alternative pain management during reviews. Concerns were also raised about systems for discussing dosage implications with patients and recording such discussions.
Addressed to: Manor Field Surgery
AI-generated concerns summaryThe coroner identified a lack of co-ordinated mental health service transfers between NHS Trusts, as removing a user from the Care Programme Approach led to GP-mediated referrals, delaying intervention and hindering information exchange.
Addressed to: Chester Hospital NHS Trust; Mersey Care NHS Trust; Cheshire Wirral Partnership
AI-generated concerns summaryThe coroner noted there is no apparent limit on the amount of loperamide medication that can be purchased from a single store, making it easier to acquire large quantities. This raises concerns due to the potential for misuse and the risk of overdose.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted a lack of clarity regarding whether awareness about a specific risk had been raised at local or national levels with relevant community and religious organisations.
Addressed to: Asra Housing Group - Nazarana Court; Chief Fire and Rescue Officer; Indian Hindu Welfare Organisation
AI-generated concerns summaryThe Fire Service unit departed a dangerous flooding scene without ensuring the road was closed or warning signs were left. South Wales Fire and Rescue Service units lack equipment and protocols to close roads, relying on other authorities to do so.
Addressed to: South Wales Fire and Rescue Service
AI-generated concerns summaryInadequate pre-operative assessment failed to record significant medical history and use existing care bundles, meaning the patient was not identified as high risk for major surgery. The consent process was also inadequate, as risks were not fully discussed.
Addressed to: Sandwell and West Birmingham Hospitals NHS Trust
AI-generated concerns summaryA radiology procedure was performed despite a visible pneumothorax, as prior imaging was not checked, and continued after complications. The policy lacked requirements for preliminary checks and documentation, and had not been adequately reviewed.
Addressed to: Barking, Havering and Redbridge University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a lack of accurate monitoring and recording of fluid intake and output, identifying its critical importance in sepsis management.
Addressed to: Hillingdon Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified a potential conflict of interest where a doctor, acting as both research investigator and clinician, decides on continued trial participation after adverse reactions, noting a lack of independent adjudication to manage this.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe coroner noted the designated first aider was not called to the scene, and the system for alerting them was unclear. Staff attending to the deceased also lacked familiarity with all life-saving first aid techniques.
Addressed to: Church Inn