Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted limited support for Mr Machin during a lengthy disciplinary investigation and suspension. There was no internal investigation into his dismissal process, despite its proximity to his death.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner identified a lack of specialist inpatient mental health provision for young adults in general adult psychiatric wards. Additionally, Pennine Care NHS Foundation Trust's internal investigation was inadequate, lacking independence and transparency, being conducted by directly involved staff.
Addressed to: Department of Health and Social Care; Pennine Care NHS Trust
AI-generated concerns summaryConcerns include administrative delays in patient follow-up and acting on alerts, alongside the lack of a clear protocol for obtaining custom-made grafts. The adequacy of the trust's internal investigation and the completeness of witness statements were also noted.
Addressed to: Sherwood Forest Hospital Trust
AI-generated concerns summaryThe coroner raised concerns that Ms Muldowney was refused urgent transfer to a neurosurgical unit due to a lack of intensive care beds, despite the time-critical nature of her required surgery.
Addressed to: Brighton and Sussex University Hospitals NHS Trust; Kings College Hospital; NHS England; St George’s University Hospital
AI-generated concerns summaryThe coroner noted the high inflammability of a dressing gown worn by Mr Lawton, regardless of its fabric composition. Concerns were raised about potential measures in production, import, or retail to reduce inflammability or warn customers of the danger.
Addressed to: Marks and Spencer
AI-generated concerns summaryThe coroner noted concerns that untreated pressure ulcers can lead to severe complications in the elderly, identifying an insufficient number of Tissue Viability Nurses in both community and hospital settings. An urgent review was deemed necessary to address these resource gaps.
Addressed to: Luton and Dunstable Hospital; South Essex Partnership NHS Trust
AI-generated concerns summaryThe coroner identified ineffective communication between nurses and the general practitioner regarding ongoing significant pain levels that were impeding care provided.
Addressed to: Rotherham, Doncaster and South Humber NHS Trust
AI-generated concerns summaryConcerns noted incomplete and inaccurate medical record-keeping, delays in transferring a patient for emergency stroke care, and delayed review of critical blood results. An unconnected pain relief device also meant analgesia was not delivered.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner noted concerns regarding fire safety, specifically that front doors of flats likely lack proper self-closing mechanisms and do not comply with the 30-minute fire-resistant British Standard.
Addressed to: London Borough of Camden
AI-generated concerns summaryConcerns include inadequate handover between wards regarding falls risk, incomplete nursing notes, and deficiencies in the system for allocating one-to-one care for high-risk patients.
Addressed to: ABMU Health Board; Welsh Assembly Government
AI-generated concerns summaryThe coroner noted a lack of family notification or consultation in the discharge decision, the absence of a discharge plan or follow-up support, and no contemporaneous notification of the discharge to Mrs Lewis's GP.
Addressed to: Aneurin Bevan University Hospital Board
AI-generated concerns summaryThe coroner raises concerns that future staffing reductions at HMP Erlestoke, exacerbated by benchmarking that does not account for prisoner types, could create an unsafe working environment for officers and compromise the safeguarding of prisoners.
Addressed to: National Offender Management Service
AI-generated concerns summaryA safeguarding referral made by a GP was not acted upon despite automated acknowledgment, and it was unclear if this was due to human or IT error.
Addressed to: Sheffield City Council
AI-generated concerns summaryThe layout of the health centre car park leads to potential conflict between pedestrians and car drivers, as patients parking in disabled spaces must cross the car park without a dedicated crossing or marked path.
Addressed to: Solent NHS Trust
AI-generated concerns summaryThe coroner noted a potential training deficit in supporting patients withdrawing from nicotine addiction, particularly for suicidal patients within the hospital's non-smoking policy.
Addressed to: Bowmere Hospital
AI-generated concerns summaryThe coroner noted a lack of in-patient facilities to admit patients with addiction for care and supervision when in crisis, raising concerns about the risk of suicide in such circumstances.
Addressed to: South West and St George’s Mental Health Trust; West London Care Commissioning Group
AI-generated concerns summaryThe coroner noted a question raised by the British Parachute Association (BPA) board regarding whether the deceased was progressed beyond her abilities, considering the time periods between her later jumps, a question the BPA Chief Operating Officer considered valid.
Addressed to: British Parachute Association
AI-generated concerns summaryThe coroner identified a lack of next of kin involvement in a significant decision for a patient with declining cognitive function. There were also no notes on the patient's medical record regarding the rationale, consent, or capacity assessment for a change of GP.
Addressed to: East Leicestershire and Rutland Clinical Commissioning Group; Hazelmere Medical Centre; Northfield Medical Practice
AI-generated concerns summaryInadequate communication and liaison between the hospital, GP practice, and district nurses regarding the deceased’s ongoing care post-discharge. Additionally, monitoring of the deceased’s condition from the hospital was not robust enough, and there was miscommunication with the family about the deceased's declining health.
Addressed to: Cancer Governance Board; Mid Cheshire NHS Trust
AI-generated concerns summaryThe coroner noted that removing resident transfer information from display in rooms made it harder for staff to access, potentially leading to inappropriate transfers and injuries. There were concerns about the CQC's role in advising homes to implement and display such information.
Addressed to: Care Quality Commission; London Borough of Wan; Meadbank Care Home; Westminster City Council