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 nurses did not observe a humidifier had been turned off during checks and handovers, and there were delays in identifying and replacing a blocked endotracheal tube. The humidifier machine also lacked an alarm to indicate when it was off.
Addressed to: Fisher and Paykel; HCA Health Care UK; London Bridge Hospital; Care Quality Commission; Nursing Midwifery Council
AI-generated concerns summaryThe coroner raised concerns that the 'Drive Clean System', which promotes smooth driving, might impede a driver's ability to perform sudden evasive steering or braking. A review of the system's operation and associated training was suggested.
Addressed to: First Mainline
AI-generated concerns summaryThe coroner raised concerns about the absence of policies at the Trust regarding the process for ordering investigative tests and ensuring their results are communicated to the consultant in charge.
Addressed to: Salford Royal Hospital
AI-generated concerns summaryThe coroner noted imprecise guidance for categorising referral urgency, specifically the lack of a default to urgent when screening was not possible or in cases of doubt. There were also concerns regarding ineffective communication between administrative and clinical staff.
Addressed to: 5 Boroughs NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that a stair lift at 7 Radnor St poses a fall risk because its step plate is suspended over the stair well when at the top. There is a concern that other properties might have similar unsafe stair lift installations.
Addressed to: Your Housing
AI-generated concerns summaryThe coroner raised concerns that the potential side effect of Ciprofloxacin, which can cause depression or psychosis leading to suicidal ideation, is not clearly communicated to patients or sufficiently emphasized to prescribing clinicians.
Addressed to: Bayer Plc
AI-generated concerns summaryThe coroner identified that discoloured amniotic fluid, even when not purulent or blood-stained, should always be sent for immediate microbiological analysis with prompt follow-up of results. A guideline implementing this action is recommended as a wise precaution.
Addressed to: British Maternal and Fetal Medicine Society; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted that the crisis team did not routinely involve family members in patient care, potentially losing valuable input. Additionally, a patient's family members made repeated unreturned calls to Crisis House, resulting in lost information and increased anxiety.
Addressed to: Camden and Islington NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding unfinalised discharge planning for patients with personality disorders and deficiencies in risk assessment processes. These included issues with form clarity, doctor sign-off, and terminology in the Missing Person Procedure, alongside unrecorded third-party information.
Addressed to: Kent and Medway NHS
AI-generated concerns summaryThe coroner noted delays in hospital admissions due to insufficient bed availability. This issue is exacerbated at weekends when fewer patients are discharged, leading to bed blocking.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner notes that the Neonatal Unit at Watford General Hospital is inadequate for the high number of annual births, and a proposal for its expansion was rejected, posing a risk to babies' lives.
Addressed to: Watford General Hospital
AI-generated concerns summaryThe coroner raised concerns regarding an employee's 13-year exposure to white spirit, which included both direct skin contact and vapour inhalation, leading to their death.
Addressed to: Amphenol Thermometrics (UK) Ltd
AI-generated concerns summaryThe coroner questioned whether the erection of an accident warning sign at a hazardous junction, where a roundabout had been proposed for years, would necessarily involve a review of the maximum speed for approaching vehicles.
Addressed to: Taunton Deane District Council
AI-generated concerns summaryThe coroner identified gaps in updating patient risk assessments, managing patients when care co-ordinators depart, and effective communication among mental health professionals. Difficulties for psychiatrists in accessing Home Treatment Team Services were also noted.
Addressed to: Rotherham NHS Trust
AI-generated concerns summaryIssues were identified concerning staff understanding and management of best interests meetings, the accurate identification of patient capacity, and the correct implementation of Deprivation of Liberty Safeguarding procedures. These deficiencies led to inaccurate meeting minutes and DoLS applications.
Addressed to: Abbey Court Independent Hospital
AI-generated concerns summaryThe coroner identified a lack of written policy, systematic checklist, and refresher training regarding referrals to the Speech and Language Therapy (SALT) team after choking incidents, which resulted in missed referrals on two occasions.
Addressed to: CLS Care Services
AI-generated concerns summaryThe coroner identified poor management, a lack of clear policies, and staff and resource shortages due to financial difficulties. Concerns also included delayed referrals for a resident's pressure ulcers and weight loss, and insufficient follow-up on medical advice.
Addressed to: Care First Homes
AI-generated concerns summaryThe coroner suggests reviewing regulations for mandatory provision of static line parachutes in certain aircraft. Concerns also include the need for mandatory spin recovery training for specific light aircraft types and ensuring pilots are proficient in recovering their specific aircraft from uncontrolled conditions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner recommended reviewing regulations for mandatory static line parachutes in certain aircraft types. Concerns were also raised about the lack of mandatory spin recovery training for specific light aircraft used for aerobatics, and ensuring pilot proficiency for these aircraft.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of specific policy for managing self-harm risks from items in an adolescent psychiatric unit, which led to inconsistency. Concerns also included the absence of a laryngoscope in the unit's emergency equipment, an item previously used successfully.
Addressed to: Resuscitation Council (UK); South London and Maudsley NHS Trust