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 lack of specialist facilities and personnel at the isolated hospital. Concerns included non-adherence to PEG insertion guidance and lack of formal training, delays in post-operative management, and poor communication between staff.
Addressed to: Care Quality Commission; Department of Health, NHS England; Queen Victoria NHS Trust
AI-generated concerns summaryThe coroner identified gaps in follow-up for a critical scan, insufficient communication with the general practitioner regarding ongoing investigations, and procedural issues that led to the cancellation of an essential outpatient appointment.
Addressed to: Kings College Hospital
AI-generated concerns summaryThe coroner identified that the NHS Pathways protocol for ambulance call handlers does not include "dizziness" and "patient on their own" as rapid response triggers for catastrophic haemorrhage. There are also insufficient clinically trained call handlers and a lack of clinical supervisors available for advice and oversight.
Addressed to: NHS England; South Western Ambulance NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the failure to transfer the patient for essential dialysis treatment and the lack of a plan for managing her deteriorating condition while awaiting transfer. There were also issues with timely consideration of alternative temporary dialysis and communication between the two hospitals.
Addressed to: Salford Royal Hospital; Royal Albert Edward Infirmary
AI-generated concerns summaryThe coroner noted the absence of warning signs for slippery road conditions on a specific stretch of road, despite numerous past incidents where this was a factor, potentially putting drivers at risk.
Addressed to: Doncaster County Council
AI-generated concerns summaryThe coroner noted that guidelines relating to sedation use should be more widely disseminated to clinicians. NHS England should also highlight the problems of sedation, particularly in the elderly, and encourage local training for hospital staff.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted insufficient guidance for reviewing or revoking Section 17 leave upon ward transfer or to a PICU, and raised concerns about the need for Responsible Clinicians to be informed of such transfers for leave review. The report also suggested applying lessons from a study on the efficacy of …
Addressed to: Chief Medical Officer for Wales
AI-generated concerns summaryThe coroner notes persistent issues with Emergency Department admission, resource availability, and patient flow continue to place lives at risk. An effective system plan to address these long-standing problems has not yet been agreed despite previous reports.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted the continued wide availability and sale of slimming products, particularly a hot slimming cream, which medical opinion indicated likely contributed to a fatal inflammatory response.
Addressed to: Hertfordshire Trading Standards; National Food Crime Unit, Food Standard Agency
AI-generated concerns summaryThe coroner raised concerns about the fire hazard of emollient creams with low paraffin content, citing inadequate warnings on packaging and insufficient awareness of these risks. Locala also did not update risk assessments after significant patient changes.
Addressed to: Arjo Huntliegh; Care Quality Commission; Department of Health and Social Care; Locala; Medicines and Healthcare products Regulatory Agency; NHS Improvement; Proprietary Association; Thornton and Ross Ltd; UK Home Care
AI-generated concerns summaryThe coroner identified insufficient input from outside consultants into the care of mental health patients, delays in rectifying ligature points due to bureaucratic processes, and a lack of effective systems for tracking dangerous items taken from and returned to patients.
Addressed to: British Association of Dermatologists; British National Formulary; Cwm Taf University Health Board; Department of Health and Social Care; Royal College of Psychiatrists; NHS England; Welsh Government
AI-generated concerns summaryThe coroner identified a lack of consultant review for patients over weekends, difficulties with nurses accurately calculating early warning scores, and poor record keeping by medical staff. These issues risk timely diagnosis, escalation, and overall patient safety.
Addressed to: Department for Health
AI-generated concerns summaryThe coroner noted inaccurate falls risk documentation, a lack of staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes following a fall. There was also a lack of understanding regarding triggers for community nutrition team referrals.
Addressed to: Fairfield View Care Centre; Tameside Borough Council
AI-generated concerns summaryRoutine delays in dispatching discharge summaries meant GPs were not informed of patient hospital stays or discharge plans, and no system ensured follow-up appointments were booked pre-discharge. Additionally, a shortage of CT angiogram slots caused diagnostic delays.
Addressed to: Tameside and Glossop Integrated Care NHS Trust
AI-generated concerns summaryThe coroner noted the absence of CCTV in corridors and communal areas at Woodlands Acute Care, which hindered the rapid location of vulnerable patients. Installing CCTV could save valuable minutes in such situations.
Addressed to: Department of Health and Social Care; Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner identified a lack of full disclosure of a child's background information to prospective foster carers and insufficient formal documentation of what was shared. This created uncertainty and increased anxiety for the child regarding their placement.
Addressed to: Ofsted
AI-generated concerns summaryCoroner noted severe Polyporus Squamosus decay in a tree went undetected, potentially due to misdiagnosis with a less urgent condition. The report recommends that diseased trees in public areas or near highways undergo specific examination and testing for Polyporus Squamosus, leading to felling if identified.
Addressed to: National Tree Safety Group
AI-generated concerns summaryThe coroner identified gaps in Beko's product recall communication, noting that notices sent by standard mail lacked delivery confirmation and follow-up attempts were insufficient, resulting in the deceased being unaware of a hazardous recalled appliance.
Addressed to: Beko Plc
AI-generated concerns summaryThe coroner asked the CQC to consider recommendations from a Root Cause Analysis Report during future care home inspections and to review the nature of their inspections based on identified learning points.
Addressed to: Care Quality Commission
AI-generated concerns summaryIneffective diary systems for referrals and incident reporting were noted, alongside inadequate communication with family members. Concerns were also raised about delays in staff physically attending to and examining a patient following unwitnessed falls.
Addressed to: Leicestershire NHS Trust