Browse 6,458 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 a lack of automatic consideration for significant medication changes when determining a patient's level of contact with mental health services.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe process for transferring missing persons cases between police forces can delay risk assessment and investigation ownership for the receiving force. There are training gaps for transferees regarding the COMPACT system, relying on officers accessing intranet guidance during busy periods.
Addressed to: Northamptonshire Police
AI-generated concerns summaryThe coroner noted concerns regarding SCAS's initial symptom recording and call category upgrades, a significant delay before clinical review, and a lack of guidance for the family. Persistent ambulance-to-hospital handover delays continue to impact emergency service availability.
Addressed to: Department of Health and Social Care; East Midlands Ambulance Service; South Central Ambulance Service; University Hospitals of Northamptonshire
AI-generated concerns summaryThe coroner noted a scan was missed due to human error and expressed concerns that an audit of new radiology scanning processes was not completed, offering no reassurance on their effectiveness or prevention of future missed urgent scans.
Addressed to: Hull Royal Infirmary
AI-generated concerns summaryThe coroner noted that patient observations were not completed according to escalation guidance, and deterioration was likely ongoing but only appreciated later. Ward bed capacity had increased due to winter pressures without a corresponding rise in nursing staff.
Addressed to: Bradford Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that 83% of obstetricians at the trust had not completed specific training arising from this incident, despite the trust's stated commitment to learning.
Addressed to: Royal Berkshire Hospital
AI-generated concerns summaryThe coroner noted a lack of national guidance and specific training for managing impacted fetal head during caesarean sections, despite this obstetric emergency becoming increasingly common.
Addressed to: Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted insufficient medication review by the GP for a patient who repeatedly disclosed overdose attempts with prescribed drugs, leading to continued large-amount prescriptions without further clinical rationale. Concerns were also raised about whether communication from a drug and alcohol service reached the treating GP.
Addressed to: Your Health Partnership Regis Medical Centre
AI-generated concerns summaryThere was no national policy for sharing information about prisoners receiving psycho-social support for substance misuse during transfers between prisons, leading to a gap in continuity of care.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a risk of falls from a specific location due to its relatively low wall and height, which could result in death. It was noted that this location might be sought out by others with suicidal thoughts.
Addressed to: Chesterfield Borough Council
AI-generated concerns summaryThe coroner noted no opportunity for pursuing drivers to communicate dynamic risk assessments to control centres and that drivers had too many tasks, leading to missed critical information. It was also stated that pursuits would be safer with a double-manned crew.
Addressed to: Home Office; South Wales Police
AI-generated concerns summaryThe coroner identified a lack of unified leadership and governance at Castlegate & Derwent Practice, alongside an absence of a robust method for investigating incidents.
Addressed to: Castlegate & Derwent Surgery
AI-generated concerns summaryHealthcare staff at HMP Chelmsford experienced difficulties navigating System One records to find previous self-harm incidents, potentially due to insufficient awareness of the importance of searching these records and inadequate training.
Addressed to: HCRG Care Group
AI-generated concerns summaryAccess to the steps is difficult as the handrail is too low and does not extend high enough for individuals to steady themselves before descending.
Addressed to: Landlord
AI-generated concerns summaryThe coroner raises concerns that hospital records lacked key detail regarding observations and the rationale for clinical decision-making, which could adversely impact the care of future patients.
Addressed to: West Suffolk Hospitals
AI-generated concerns summaryAn unprotected fire escape at a rehabilitation unit allowed easy access to the roof from the garden, with no environmental risk assessment completed for this structural vulnerability. The coroner noted a lack of guidelines for fire escape protections in rehabilitation settings.
Addressed to: Birmingham and Solihull Integrated Care Service; Care Quality Commission; NHS England
AI-generated concerns summaryThe coroner noted the availability of online information for constructing certain items and that possession of materials for these items is not a criminal offence, creating a risk until proposed legislation is enacted.
Addressed to: Department of Health and Social Care; Home Department
AI-generated concerns summaryThe coroner identified a lack of a system to ensure important healthcare information, including medication details and physical observations, is passed between different healthcare providers in the criminal justice system during transfers. There is also no standard medical records system accessible by all providers for efficient information transfer.
Addressed to: IPRS Aeromed; Mitie; NHS England; Practice Plus Group
AI-generated concerns summaryThe coroner raises concerns about the Liaison and Diversion Team at Northampton no longer operating a Saturday Court Service, previously covered by an 'On Call' service, noting this absence could risk future deaths.
Addressed to: Northamptonshire Healthcare Foundation Trust
AI-generated concerns summaryThe coroner identifies insufficient discussion of SUDEP risks with epilepsy patients, citing doctors' reluctance, a presumption of prior conversations, and a lack of universal tools. SUDEP also being absent from medical training contributes to gaps in patient awareness.
Addressed to: Department of Health and Social Care