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 evidence suggesting Isabel's death from meningitis B could have been prevented by vaccination, raising concerns about the ongoing risk to teenagers as the vaccination program does not include this age group.
Addressed to: Committee of Vaccination and Immunisation; Department of Health and Social Care; John Ratcliffe Hospital; Oxford University
AI-generated concerns summaryThe coroner noted that a patient transfer backup plan relied on a bed that was unavailable, raising concerns that clinicians lacked real-time bed status information across the Trust's multiple sites when devising the plan.
Addressed to: University College London Hospitals NHS Trust
AI-generated concerns summaryConcerns relate to the accuracy of patient record keeping, particularly for urine output, and the timeliness of patient reviews when there is no improvement in condition. The coroner also noted the need to review sepsis guidelines and the training provided to locum and temporary staff.
Addressed to: Great Western Hospitals NHS Trust; NHS England
AI-generated concerns summaryThere is no alarm or warning system to notify the signaller when a person passes through the gate to the tracks at the end of the platform.
Addressed to: RSSB
AI-generated concerns summaryThe coroner noted that Mrs Thompson, a post-splenectomy patient, was not receiving lifelong antibiotic prophylaxis or specific vaccination, particularly around a recent surgical procedure. Concerns were also raised regarding the clarity of advice from health agencies about the importance of antibiotic prophylaxis.
Addressed to: Public Health England
AI-generated concerns summaryThe coroner identified inadequate supervision for the SHO, delays in consultant engagement, obtaining test results, and administering critical treatments. There were also concerns regarding insufficient patient monitoring in the A&E department.
Addressed to: Royal Surrey County Hospital NHS Trust
AI-generated concerns summaryThe coroner noted that the parameters for activating the Supplementary Restraint System (airbags) may require adjustment to ensure deployment in collisions, especially when impacts occur at the front centre of the vehicle, away from sensor locations.
Addressed to: Department for Transport; Driver and Vehicle Standards Agency; Honda UK
AI-generated concerns summaryThe coroner identified a breakdown in communication leading to Mrs Smith and her GP not being informed of a thoracic aneurysm, which consequently was not placed under surveillance.
Addressed to: Bute House Surgery; Yeovil District Hospital
AI-generated concerns summaryThe coroner noted an apparent lack of a specific audit of possible ligature points on the wings since December 2015.
Addressed to: HMP Grendon
AI-generated concerns summaryThe coroner noted ongoing risks from unsafe prescribing of controlled drugs by Ivy Grove Surgery and a limited understanding of reporting serious prescribing incidents. Concerns were also raised about poorly coordinated management and prescribing for neurological patients under shared care.
Addressed to: Derbyshire Community Health Services; Ivy Grove Surgery
AI-generated concerns summaryThe coroner noted no referral was made back to the Mental Health Liaison Service when Ms Baynham left hospital, which could have led to a further assessment of her mental state and risk of self-harm.
Addressed to: Black Country NHS; New Cross Hospital
AI-generated concerns summaryThe coroner noted insufficient information sharing between authorities about road incidents, particularly "damage only" events and precise location details. Concerns were also raised regarding the risk assessment of a specific location, including its funding prioritisation and recognition of hazards.
Addressed to: Amey PLC; Sheffield Council; South Yorkshire Police; Yorkshire Water PLC
AI-generated concerns summaryThe health board's guideline for naso-gastric tube insertion and confirmation was outdated, and national guidelines advocating pH testing after insertion were not followed. Additionally, the insertion checklist was not consistently applied, with no clear guidance in place for the ITU setting.
Addressed to: CWM Taf University Health Board
AI-generated concerns summaryThe coroner noted a pharmacy allowed customers to interchangeably collect each other's prescriptions without documented consent, raising concerns this practice could facilitate abuse, stock-piling, and increased risk of harm.
Addressed to: Adams Pharmacy; the relevant regulator of pharmacies
AI-generated concerns summaryThe Probation Trust placed high-risk offenders in unsuitable supported living accommodation, lacked dynamic risk assessments, and did not provide timely information. Liverpool City Council missed opportunities for oversight and validation visits of the accommodation provider and the Probation Trust.
Addressed to: Liverpool City Council; National Offender Management Service
AI-generated concerns summaryThe coroner noted restricted visibility at the junction of Highmoor Road and Albert Road due to a house, fence, and trees, making it difficult for drivers to safely pull out. Improvements to the junction were suggested to increase visibility and reduce collisions.
Addressed to: Transport Manager, Reading Borough Council
AI-generated concerns summaryThe coroner noted a lack of specific training for a prison officer beginning night shifts, particularly concerning the night patrol regime. Additionally, initial responding staff did not have first aid training, prompting a review of basic resuscitation training for officers and staffing quotas.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner identified issues with prescribing methadone over the telephone without a face-to-face consultation, which resulted in insufficient patient information. Additionally, providing a methadone-naive patient with a seven-day supply lacked initial medical review.
Addressed to: Dinnington Group Practice; Yorkshire Ambulance Service NHS Foundation Trust
Addressed to: Care UK; HMP Pentonville; National Offender Management Service; NHS England
AI-generated concerns summaryThe coroner raised concerns that endoscopy discharge summaries were posted rather than emailed to GP practices, causing delays in GPs receiving critical patient information and potentially impacting patient care.
Addressed to: Portsmouth Hospitals NHS Trust