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 that the doctor performing a FAST ultrasound was not properly trained or supervised, and that records of these examinations are not routinely stored. The report further identifies a need for appropriate care escalation when a symptomatic Abdominal Aortic Aneurysm is identified in the emergency department.
Addressed to: Cardiff and Vale University Health Board
AI-generated concerns summaryThe coroner noted that ambulance dispatch protocols and resource review were not followed, with a lack of a safety net system and insufficient staff knowledge of protocols. Time limits were breached without escalation or resource allocation.
Addressed to: Yorkshire Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted that ambulance staff did not cross-check for a shockable rhythm or routinely use a defibrillator in AED mode. Concerns were raised regarding the need for staff training on these procedures and the interpretation of shockable rhythms.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted that GPs lacked direct urgent access to CT scanning, unlike those in neighbouring areas, identifying this as a commissioning issue that could affect patient outcomes.
Addressed to: Bury Clinical Commissioning Group
AI-generated concerns summaryThe coroner identified insufficient enhanced observation for high falls-risk patients and a lack of evidence for the implementation of plans for increased observation and meaningful activity. There were also concerns about the effectiveness of non-slip hospital footwear.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted issues with the operation and training related to the PAR scoring system, the absence of nurses' medical notes for doctors, and the incorrect diagnosis of pulmonary embolism by medical staff.
Addressed to: Dartford and Gravesend NHS Trust
AI-generated concerns summaryThe coroner noted persistent significant staffing shortages in the Intensive Care Unit, particularly for Clinical Fellows, which affected consultants' ability to fully dedicate time to clinical care and impacted patient care. Concerns were raised about ongoing gaps in the rota, especially during summer months.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe surgical team was unaware of Mr Mullins' history of vein thrombosis. Despite deteriorating NEWS scores, a clinician did not see him in a timely fashion, and the initial clinician contacted indicated this was to be expected post-surgery.
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryThe coroner noted a lack of documented records regarding family concerns about suicide risk communicated to hospital staff, particularly concerning telephone conversations. There were also no current systems for monitoring or recording such calls to verify their content.
Addressed to: Tees, Esk and Wear Valley NHS Trust
AI-generated concerns summaryThe GP practice's system for monitoring and actioning hospital letters was insufficient, leading to missed vaccinations. Concerns were also raised about the availability of the pneumovax23 vaccine and GPs' understanding of how to access it.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified challenges in information sharing between mental health services in West Sussex and Surrey. Professionals cannot easily access patient data across county lines, and clinical records from s.136 assessments are not routinely shared.
Addressed to: Surrey and Borders Partnership NHS Trust; West Sussex County Council
AI-generated concerns summaryThe coroner identified a lack of awareness among A&E and surgical staff regarding the impact of decompensated liver failure on clinical management and insufficient knowledge of early hypovolaemia signs and treatment. Additional concerns included inadequate consultant input for complex cases and issues affecting the mortality review process.
Addressed to: Lancashire Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted disrepair in sections of fencing and walls separating a public footpath from the railway line, which created easy opportunities for individuals to access the railway.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified that an 'opt-in' letter, deemed necessary for the deceased, was not sent. There were also concerns about the 10-day delay in sending such letters and the requirement for a typed letter rather than a more efficient pre-printed option.
Addressed to: East London NHS Trust
AI-generated concerns summaryThe coroner identified that the school had insufficient emergency contact information, delayed acting on unexplained non-attendance for several days, and lacked a protocol for immediate police contact when welfare checks at home were unsuccessful.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted concerns regarding high caseloads for care coordinators, with some managing 75-80 service-users, and these levels persisting despite the Trust's plans for reduction and its own internal investigation findings.
Addressed to: Kent and Medway NHS Trust
AI-generated concerns summaryThe coroner noted a lack of clear guidance for community district nurses on GP involvement and insufficient systems for sharing information or escalating concerns among various partner agencies and care providers involved in community patient care.
Addressed to: East London NHS Trust; Homerton University NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the appropriate escalation of care for patients who acutely deteriorate during night shifts over weekend periods.
Addressed to: Gloucestershire Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns that information about the potential hazard of confused patients consuming alcohol-based hand gels has not been widely disseminated across the NHS and other sectors. Organisations should be aware of this risk and conduct appropriate formal risk assessments.
Addressed to: NHS England
AI-generated concerns summaryThe process for managing unexpected non-cancerous radiological findings relies on a single doctor noticing and recording the information, lacking a 'red flag' system. No specific protocol exists for these findings, unlike that for unexpected cancer pathology.
Addressed to: Department of Health and Social Care