Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified a possible conflict between healthcare staff's risk assessment methods and ACCT policy requirements for prisoners. Concerns were raised that healthcare staff required clearer training on the ACCT process and its lower threshold for intervention.
Addressed to: Avon and Wiltshire Mental Health NHS Trust; Bristol Community Health; HMP Bristol
AI-generated concerns summaryThe coroner identified gaps in communication between different software packages, leading to a patient's allergy marker being missed and an antibiotic administered despite a known allergy.
Addressed to: Great Western Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted concerns that an illuminated advertising board obstructed views for pedestrians and drivers, and that overhanging tree canopies compounded visibility issues. This may be linked to a reduction in tree lopping and an increase in road traffic collisions.
Addressed to: Highways England; Oldham Council
AI-generated concerns summaryThe report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a lack of documentation for carer visits and no system for recovering care notes when care ceased. Additionally, no discharge summary was provided to the GP after the deceased's A&E visit.
Addressed to: Tameside General Hospital; Tameside Metropolitan Borough Council
AI-generated concerns summaryThe coroner identified a lack of documentation for therapy selection, unclear triggers for referrals, and limited information sharing among health professionals. There was also no formal process for escalating health professional concerns.
Addressed to: Grosvenor Medical Centre Stalybridge; Pennine Care NHS Trust
AI-generated concerns summaryA patient with suicidal thoughts was prescribed a large quantity of antidepressant medication, and there was no system to flag his notes to limit repeat prescriptions from the GP practice.
Addressed to: Woodley Centre Surgery
AI-generated concerns summaryThe safeguarding notice was not acted upon, specifically a request for referral to Mental Health Services, due to a lack of clarity among staff regarding whether the notice required follow-up action.
Addressed to: North Lincolnshire Council
AI-generated concerns summaryThe coroner noted a lack of a robust protocol to ensure all relevant personnel are aware of documented mental health observation levels. Concerns were also raised about insufficient recognition of risks when allowing a patient, under Mental Health Act detention, to leave the hospital.
Addressed to: Barnet, Enfield and Haringey Mental Health NHS Trust; Camden and Islington NHS Trust; Whittington Health NHS Trust
AI-generated concerns summaryThe coroner noted failures to record the reviewing doctor's name on ECGs and to consider previous abnormal ECG results during paramedic handovers.
Addressed to: Royal Wolverhampton NHS Trust
AI-generated concerns summaryThe coroner noted that thromboprophylaxis was not arranged and no effective risk assessment for developing blood clots was undertaken. A review of policy and training for staff regarding thromboprophylaxis for immobile patients was suggested.
Addressed to: Dudley Group of Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about a GP's incorrect referral for vascular screening and a lack of a hospital system to direct such requests, leading to refusal. Issues also included GP uncertainty regarding the screening programme criteria.
Addressed to: East Leicestershire and Rutland Clinical Commissioning Group; The Glenfield Surgery; University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner noted no effective system exists for prisoners' families to input relevant health information and ensure its dissemination to prison teams and proper recording. Concerns were also raised about the ineffective measures to control contraband, such as illicit drugs like Spice, entering the prison.
Addressed to: HMP Wandsworth; Home Office
AI-generated concerns summaryThe coroner raised concerns about post-detoxification care, asking whether individuals should receive fixed appointments, telephone contact between discharge and first review, and increased availability of an alcohol liaison nurse.
Addressed to: Department of Health and Social Care; Kings College Hospital; South London and Maudsley NHS Trust
AI-generated concerns summaryThe coroner noted significant delays in obtaining fitness to plead reports for an individual remanded in custody, with a lack of clarity over which authority was responsible for commissioning them. This contributed to the individual's deteriorating mental state and an inappropriate reduction in observation frequency.
Addressed to: Central and North West London NHS Trust; HM Courts and Tribunals Service; HM Prison and Probation Service; Ministry of Justice
AI-generated concerns summaryThe coroner identified serious delays in ambulances arriving at incident scenes.
Addressed to: Brighton and Sussex University Hospitals NHS Trust; SECAMB
AI-generated concerns summaryThe coroner noted that CCTV at Earlestown station did not cover all platform areas, meaning staff could not see the deceased on the tracks. There was also no physical barrier at the end of platform three, allowing unfettered access to the tracks.
Addressed to: Northern Rail
AI-generated concerns summaryPolice training was insufficient on restraint techniques, the understanding of Acute Behavioural Disturbance (ABD), and the meaning of 'prolonged restraint'. The report also notes a lack of clarity on police and healthcare roles and issues with hospital staffing policy adherence.
Addressed to: Metropolitan Police; South London and Maudsley NHS Trust
AI-generated concerns summaryThe coroner noted that pedestrians frequently wait in the hatched road area and vehicles pass parked vehicles there, leading to confusion and posing a risk for both pedestrians and motorists.
Addressed to: Sandwell Local Authority
AI-generated concerns summaryThe coroner identified unreliable processes for relaying patient messages to the Multi-Disciplinary Team (MDT), leading to inappropriate discharge. Further concerns included the MDT not discussing referred patients and inadequate record-keeping during meetings.
Addressed to: Lancashire Care NHS Foundation Trust