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 the absence of a 24-hour consultant plastics surgical service at KCH, a regional trauma centre. This poses risks for patients needing urgent specialist debridement for conditions like necrotising fasciitis, where delays can be fatal.
Addressed to: Department of Health; Kings College Hospital; NHS England
AI-generated concerns summaryConcerns were raised that other travel companies may lack security advisors at board level and may not prominently display links to the Government's Travel Aware programme, potentially impacting hotel security and public awareness of terrorist risks.
Addressed to: ABTA; Civil Aviation Authority; Department for Transport; Foreign, Commonwealth & Development Office
AI-generated concerns summaryThe coroner noted the absence of peritoneal dialysis arrangements at Maidstone Hospital, including a lack of trained staff, equipment, and a system for transporting equipment from patients' homes, compounded by clinicians' unawareness of these limitations.
Addressed to: East Kent Hospital Foundation Trust
AI-generated concerns summaryThe coroner identified issues with communication barriers among care home staff due to poor English proficiency, contributing to a chaotic emergency response and poor decision-making. Concerns were also raised about staff lacking first aid training and inadequate contemporaneous record-keeping.
Addressed to: Boldmere Court Care Home; Care Quality Commission; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the perception that phone chargers are not risky, particularly when in contact with water, and identified a need for clearer warnings.
Addressed to: Apple
AI-generated concerns summaryThe coroner raised concerns that mental health clinicians did not contact external providers when a patient was receiving treatment elsewhere, and that a worsened patient's condition did not trigger a prompt consultant psychiatric assessment.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the practicality, adequacy, and reliability of hourly observations, including difficulties in assessing breathing through door windows and inaccurate recording of patient positions. The Trust's observation policy also lacked clarity and direction for staff.
Addressed to: Coventry & Warwickshire Partnership NHS Trust
AI-generated concerns summaryThere was no process for completing risk assessment plans when a resident's needs changed from care to nursing, leading to communication gaps between the care home and District Nursing Team. Patient records lacked detail and the correct procedure for pressure relieving strategies was not consistently followed.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner identified the need for a national review of serious incidents in 'front door' services to inform future design. NHS 111 should immediately share information with Emergency Departments in a user-friendly format.
Addressed to: Brisdoc; NHS, University Hospital Bristol NHS Trust
AI-generated concerns summaryThe report raises concerns about the sufficiency of measures employed by the district nursing service for effective monitoring of patients' ongoing conditions.
Addressed to: Gloucestershire Care Services NHS Trust
AI-generated concerns summaryThe coroner identified a pothole in the carriageway, measured at 45mm deep, which exceeded Wigan Council's stated repair threshold of 40mm.
Addressed to: Wigan Council
AI-generated concerns summaryConcerns were raised that not all of John Ramsden's daughters were consulted about his end-of-life care and decisions regarding hospital admission for treatment.
Addressed to: Agrade Community Care Services
AI-generated concerns summaryThe coroner noted the short reaction time available for drivers to avoid a stationary vehicle at 60mph. Concerns were raised regarding the lack of restrictions on stopping vehicles at that specific location, despite a safer parking area nearby.
Addressed to: Essex Highways
AI-generated concerns summaryThe coroner noted that patients were not receiving daily senior clinician reviews and raised concerns about the interim period before new staff are recruited to address this.
Addressed to: Pennine Acute NHS Trust
AI-generated concerns summaryThe coroner noted incomplete nursing records, handovers, and care plans, with audits failing to identify these deficiencies. Concerns were also raised about patients detained under the Mental Health Act being able to abscond due to insufficient security and inadequate staffing levels.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that the chair was not fitted with sensors to detect a foot in its mechanism, which could have prevented a crushing injury and released the foot.
Addressed to: A.J Way & Co Ltd; National Trading Standards; Yorkshire Care Equipment
AI-generated concerns summaryDuring an operation, a mechanical aortic valve was remounted contrary to manufacturer instructions, without documented rationale or awareness of risks by the surgical team. An untrained scrub nurse was instructed to perform this procedure, and the primary surgeon had not instructed it.
Addressed to: Newcastle Upon Tyne NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the inappropriate termination of a call, which prevented the escalation of urgent medical assistance. There was a lack of adherence to existing call termination guidance and no subsequent staff training has been provided.
Addressed to: North West Ambulance Service
AI-generated concerns summaryThe coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
Addressed to: Department of Health and Social Care; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted that the hospital's equipment portfolio was unknown, which prevented the identification of potentially dangerous equipment, subsequent risk assessment, and actions to prevent future harm to patients.
Addressed to: DAC Beachcroft LLP; Drager; Luton & Dunstable University Hospital NHS Trust