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 identified insufficient communication to the family about crisis team limitations and anticipated illness progression. An urgent crisis line call did not result in the nurse suggesting or making an emergency call, or considering an earlier home visit.
Addressed to: East London NHS Trust
AI-generated concerns summaryThe coroner noted that while Custody Officers in Spain are trained in first aid, their training does not include instruction in Cardio Pulmonary Resuscitation (CPR).
Addressed to: Foreign, Commonwealth & Development Office
AI-generated concerns summaryThe coroner noted a significant delay in communication between the hospital and the GP surgery, leading to the GP being unaware of critical information regarding medication changes and increased INR levels for the patient.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summarySurrey County Council insufficiently considers the increasing number of cyclists on highways for defect categorisation, prioritising cycle lanes over general highways used by many cyclists, and does not specifically account for risks to cyclists during assessments.
Addressed to: Surrey County Council
AI-generated concerns summaryThe coroner noted the GP surgery's failure to action a recommended chest clinic follow-up from an A&E discharge summary, alongside a lack of contingency systems and poor attention to documents, including faxes from mental health agencies.
Addressed to: Wanstead Place Surgery
AI-generated concerns summaryThe coroner noted the deceased was discharged from mental health services without pre-arranged follow-up appointments and no attempt was made to visit him to re-engage with services. Concerns were also raised about the lack of monitoring for his changed medication after discharge.
Addressed to: South Staffordshire and Shropshire NHS Trust
AI-generated concerns summaryThe coroner noted deficiencies in handling a referral, including a lack of recorded risk level, next of kin details, and follow-up arrangements after an appointment was declined. There was also no proactive engagement with the young person's parents to facilitate access to services.
Addressed to: Child and Adolescent Mental Health Service East Cross Street Clinic; South Staffordshire and Shropshire NHS Trust
AI-generated concerns summaryConcerns were raised regarding the District Nursing Team's record-keeping system, where patient notes were held solely at the patient's address with no central contemporaneous record, leading to difficulties in evidence provision and post-death retrieval.
Addressed to: Stockport NHS Trust
AI-generated concerns summaryThe coroner identified gaps in the effective management of multiple calls, prioritisation of appliances, and protocols for their mobilisation. Insufficient staff training in verbal communication and checking appliance availability was also noted.
Addressed to: Chief Fire Officer
AI-generated concerns summaryThe coroner noted concerns about repeated cancellations and delays in hip fracture surgery due to insufficient theatre staff and resource availability, which extended beyond recommended guidelines and can lead to serious complications.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted significant delays in emergency response, including resuscitation, calling an ambulance, and defibrillator deployment and use. Concerns were also raised about inadequate staff training and induction, particularly for agency nurses unfamiliar with the ward.
Addressed to: Cambian Group
AI-generated concerns summaryThe coroner identified uncoordinated mental health care for young adults (18-25) in crisis, with unclear responsibility and ineffective information sharing between two service providers. Concerns also noted insufficient early involvement of approved social workers in Mental Health Act assessments.
Addressed to: Birmingham and Solihull Mental Health Trust; Birmingham Children’s Hospital NHS Trust; Birmingham City Council; Cross City Clinical Commissioning Group; NHS England
AI-generated concerns summaryThe coroner raises concerns about the ability of care home staff to identify when to escalate medical concerns and when a medical review should be sought.
Addressed to: Care UK
AI-generated concerns summaryThe coroner noted inadequate post-operative monitoring, unclear clinical accountability between departments, and an ongoing issue with patient transfer by porters. Concerns were also raised that the initial incident report's findings conflicted with expert evidence regarding care.
Addressed to: Barking, Havering and Redbridge University Hospital
AI-generated concerns summaryThe Care Centre lacked documentation of measures taken to treat a pressure sore and turning charts, which prevented senior staff from knowing if the condition was being treated properly.
Addressed to: DAC Beachcroft Claims Ltd; Grange Care Centre
AI-generated concerns summaryThe coroner identified significant delays in hospital admission and medical treatment, alongside recurring unacceptable delays in patient handover at the Emergency Department. These issues led to long waits in ambulances and unavailable resources, exacerbated by problems in patient flow.
Addressed to: BCUHB; HM Stanley Site; Welsh Ambulance NHS Trust; Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted a delay in summoning an ambulance for a patient with a known falls history, on Warfarin, and with an obvious head injury. This occurred despite the clear need for immediate hospital review, leading to a recommendation for policy and procedure review.
Addressed to: Gateshead Health Foundation Trust
AI-generated concerns summaryNursing staff lacked the knowledge and experience to perform neurological observations correctly or understand the seriousness of the injury, delaying a doctor's attendance. There were no adequate systems to identify inexperienced staff or provide specific falls prevention plans on the ward.
Addressed to: Queen Elizabeth Hospital NHS Trust
AI-generated concerns summaryThe coroner noted incomplete routine neuro observations and an incorrectly calculated NEWS score. This resulted in a missed medical review for the patient when one was clearly indicated.
Addressed to: Cwm Taf Morgannwg University Health Board; The Chief Coroner; Welsh Assembly Government
AI-generated concerns summaryThe coroner noted that Michael Mahon missed a required annual clozapine test in March 2016, and there was no system in place to identify that this test had been missed or to flag it during subsequent monthly checks.
Addressed to: Pennine Care NHS Foundation Trust