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 that the Tamar Bridge barrier is easily traversed, leading to 11 recorded jumps in the past decade, and asked for a review of procedures to reduce future deaths. Concerns were also raised about the risk this poses to those on Wolseley Road and the absence of sufficient …
Addressed to: Cornwall County Council; Devon County Council; Tamar Bridge & Torpoint Ferry joint Committee
AI-generated concerns summaryThe coroner identified serious communication failings and an over-reliance on agency and junior staff to make decisions. Concerns were also raised about the lack of a prompt response to the patient's deteriorating state and documentation issues.
Addressed to: Anglian Community Enterprise
AI-generated concerns summaryThe coroner identified gaps in the online prescribing process, including applications allowing false information without prescriber verification with GPs, and the inappropriate prescribing of excessive dihydrocodeine without direct patient assessment.
Addressed to: H R Healthcare Limited; NHS England
AI-generated concerns summaryThe coroner noted insufficient expertise of the mental health professional conducting the assessment of an older person who self-harmed, and inadequate access for the healthcare professional to the detainee's full medical records.
Addressed to: Mitie; NHS Wales; South Wales Police
AI-generated concerns summaryConcerns were raised regarding the absence of training records, deviations from standard diving practices and depths, and a lack of written risk assessments for the dive. Additionally, an unqualified instructor led the dive, and a problematic dive belt configuration was noted.
Addressed to: British Sub Aqua Club; Dulwich Dive Club
AI-generated concerns summaryThe coroner noted a lack of clear responsibility for booking follow-up appointments for discharged neurology patients, resulting in many patients, including Mr Millar, not receiving scheduled post-discharge care for over two years.
Addressed to: CQC, Safeguarding team; National Customer Service Centre; Secretary of State for Health
AI-generated concerns summaryThe coroner notes that safety guidance documents for internal combustion engine equipment, particularly for use in confined areas, are inadequate and potentially misleading. The use of the HSE logo on these documents risks implying official endorsement, which could exacerbate harm.
Addressed to: Department for Work and Pensions; HAE Ltd; Health and Safety Executive
AI-generated concerns summaryThe coroner noted that a holdall bag with an attached strap was left in the patient's room after staff checks, raising concerns about balancing personal item removal with least restrictive policies.
Addressed to: Care Quality Commission; Dudley and Walsall Mental Health NHS Trust
AI-generated concerns summaryThe coroner noted inadequate post-discharge mental health care and ineffective duty/buddying systems. Concerns were also raised about the expectation for severely ill patients to initiate contact and the lack of female intensive psychiatric beds in Devon.
Addressed to: Department of Health and Social Care; Devon Partnership Trust; NHS Northern Eastern and Western Clinical Commissioning Group
AI-generated concerns summaryThe coroner notes insufficient awareness among medical professionals and in NICE guidelines regarding the elevated haemorrhage risk for haemodialysis or uremic patients after a head injury. This gap in guidance could pose a risk to future patients.
Addressed to: Department of Health and Social Care; N.I.C.E; Pennine Acute NHS Trust
AI-generated concerns summaryDelays in completing Care Treatment Plans post-discharge meant patients might not see a consultant psychiatrist for up to sixteen months. Concerns were also raised about insufficient staff cover due to increasing demand on mental health services.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified an unsafe loading shovel work method, insufficient enforcement of safety rules for drivers and high-visibility clothing, and inadequate health and safety training for both staff and risk assessors.
Addressed to: MAC Skip Hire Limited
AI-generated concerns summaryThe coroner noted concerns that a GP prescribed medication based on advice from a non-prescribing nurse, resulting in the patient not receiving crucial information about potential increased suicidality or crisis support. There was also a reported lack of awareness among GPs regarding the duty psychiatrist service.
Addressed to: Cambridge and Peterborough NHS Trust; Cambridgeshire and Peterborough Clinical Commissioning Group; GP Practice Orchard Surgery; NHS England
AI-generated concerns summaryThe provided text excerpt is incomplete and does not contain discernible coroner's concerns regarding the case.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted inconsistent Healthcare attendance and documentation in ACCT reviews, a lack of process for following up missed first-night healthcare screenings, and no system to ensure officers are familiar with local directives.
Addressed to: Care UK; Family Solicitors; HMP
AI-generated concerns summaryThe coroner noted that PARAMEDIC 2 Trial exclusion criteria, including for pregnant women, were overlooked due to insufficient prominence on drug packets. There was also a lack of guidance from Warwick Medical School on how to highlight these exclusions to participants.
Addressed to: South Central Ambulance Service; Warwick Medical School
AI-generated concerns summaryConcerns relate to the auditing of staff conducting 15-minute observations and clozapine prescription, alongside the training of staff in resuscitation for patient collapse.
Addressed to: Edgware Community Hospital
AI-generated concerns summaryThe coroner noted a delay of approximately one week in notifying Mr. Jones' GP of his discharge from the Crisis Team, which meant he lacked community support. There was also no clear provision in the Crisis Team's protocols for immediate GP notification.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust
AI-generated concerns summaryThe coroner identified a lack of a formal backup plan for patients requiring PCI when primary hospitals cannot accept them, and no agreed pathway for unconscious STEMI patients needing tertiary services. This absence of capacity and clear pathways increases the risk of death.
Addressed to: ABMU Health Board; Cardiff and Vale Health Board; CWM Taff Health Board; Minister for Health & Social Services; Welsh Health Specialised Services Committee
AI-generated concerns summaryDifficulties were noted in nursing staff securing timely medical reviews for patients, with a significant delay in doctor attendance on one occasion. This raised concerns about the adequacy of medical staffing levels during out-of-hours periods.
Addressed to: Royal London Hospital