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 summaryConcerns were raised that an ACCT was not opened for an individual given distressing news, despite her being very upset. Instead, a vague instruction to "offer support" was given, with no clear plan or documentation on what support should be provided.
Addressed to: NOMS, Prison Service, Equality Rights and Decency Group
AI-generated concerns summaryHospital discharge letters contained inaccuracies regarding patient diagnoses, often completed by junior doctors who had not seen the patient, leading to potential serious mistakes in primary care.
Addressed to: NHS England; University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner noted insufficient staffing levels in the Emergency Department, which prevented adherence to national and local policies for treating suspected sepsis.
Addressed to: Chelsea and Westminster Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the challenging nature of the junction, evidenced by multiple 'near miss' incidents and a history of four other fatal collisions, two involving vehicles turning across southbound traffic. Additionally, HGVs experienced prolonged waiting times to turn safely.
Addressed to: Lincolnshire County Council
AI-generated concerns summaryA lack of local psychiatric intensive care unit beds for female patients, ineffective community psychiatric nurse involvement, and insufficient community support for patients were noted. Additionally, the care programme approach was not adhered to.
Addressed to: Leicestershire Partnership NHS Trust; East Leicestershire & Rutland CCG; Secretary of State for Health
AI-generated concerns summaryThe coroner identified a lack of specific protocol and training for police officers monitoring non-detained members of the public in police stations, particularly regarding the assessment of medical signs like snoring, the impact of intoxication, and the sharing of relevant information.
Addressed to: New Scotland Yard
AI-generated concerns summaryThe coroner noted patients discharged with central lines lack guidance, staff showed insufficient knowledge of the central line policy, and a syringe driver failed to alarm when blocked and was reconnected without referral for repair.
Addressed to: Bolton NHS Trust
AI-generated concerns summaryThe coroner identified that there is no regulatory body for advanced nurse practitioners, meaning they are not subject to the same stringent appraisal and revalidation processes as GPs and some may operate without supervision. This lack of regulation could impact patient safety.
Addressed to: NHS England; Nursing and Midwifery Council
AI-generated concerns summaryThe coroner identified inadequate risk assessment prior to discharge, which failed to consider the patient's urgent toileting needs and difficult home staircase. There was also insufficient questioning for assessment and discharge purposes.
Addressed to: Lord Chancellor; Wythenshawe Hospital
AI-generated concerns summaryThe coroner identified concerns about DVT scanning practice, specifically the absence of lower leg scans and insufficient supervision after negative results. The report also noted poor safety-netting, delays in medical assessment and medication on re-admission, and issues with anticoagulation management.
Addressed to: Barnsley Hospital NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that the triage nurse overly focused on the patient's fall, leading to delayed observations and blood tests for potential infection. Concerns were also raised regarding insufficient observation before patient prioritisation in A&E.
Addressed to: New Cross Hospital
AI-generated concerns summaryThe coroner noted that motorcycles frequently use residential pathways, with speeds recorded up to 68 mph, posing a risk to pedestrians including children and the infirm.
Addressed to: Luton Borough Council
AI-generated concerns summaryThe coroner noted issues with ensuring parental competence for nasogastric tube (NGT) feeding and inadequate staff training on pH testing before NGT medication. Concerns also included insufficient information sharing between trusts.
Addressed to: Nottingham University Hospitals NHS Trust; Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted that a raised section of tarmac and confusing visual markings from a previous road layout on the A1(M) approaching Junction 6 northbound are potentially hazardous.
Addressed to: Highways England
AI-generated concerns summaryThe coroner raised concerns that domestically manufactured machines from 1973, exempt from helmet and seatbelt requirements, pose an inherent risk. The report suggests considering legislation to bring this class of vehicle in line with other mechanically propelled vehicles.
Addressed to: Department for Transport
AI-generated concerns summaryPrison staff at Winchester Prison were not implementing ACCT plans in line with national policy, including inadequate observations. There were also unclear confidentiality rules for Prison Listeners regarding suicide threats and limitations in the NOMIS database for recording closed ACCT plans.
Addressed to: HM Prison Service; Samaritans
AI-generated concerns summaryHounslow Social Services had a misapprehension regarding their ongoing welfare role for a child placed at a facility. They also did not assess the need for support regarding family contact, despite the mother raising difficulties.
Addressed to: Department of Health and Social Care; Hounslow Borough Council
AI-generated concerns summaryConcerns were raised about the open accessibility of uncensored online videos depicting dangerous 'choking game' activities without warnings. The coroner also identified a lack of national guidance for schools and youth groups, and no dedicated support for parents regarding these online challenges.
Addressed to: Department for Education; National Society for the Prevention of Cruelty to Children
AI-generated concerns summaryThe ACCT document process was incomplete, with information not fully used and appropriate individuals not always invited to reviews. Additionally, resourcing pressures were noted to affect officers' ability to ensure prisoner safety from self-harm.
Addressed to: HMP YOI Glen Parva; Secretary of State for Justice; National Offender Management Service
AI-generated concerns summaryThe coroner identified a gap in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither Lewisham District Nurses nor commissioned agency carers provide visits at night.
Addressed to: London Borough of Lewisham Adult Care Services; NHS Lewisham Clinical Commissioning Group