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 raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Addressed to: Avon and Wiltshire NHS Trust
AI-generated concerns summaryThe coroner noted that Pentobarbital, a drug commonly used in suicide, is not subject to strict control due to its Schedule 3 classification, indicating a potential gap in reducing access to means of suicide.
Addressed to: Advisory Council on the Misuse of Drugs
AI-generated concerns summaryThe coroner requested a review of the suitability of pedestrian railing between Paignton Railway Station and Bus Station to reduce the effects of vehicular collisions with pedestrians.
Addressed to: Highways Department, Torbay Council
AI-generated concerns summaryThe coroner noted concerns that an INR test was not performed to inform treatment, and warfarin was restarted based on an outdated reading. There is a need to clarify protocols for junior doctors regarding treatment reversal and restarting warfarin.
Addressed to: Portsmouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that a junior doctor did not review the patient despite a rapidly deteriorating NEWS score, potentially attributing symptoms to anxiety, which suggests a training need. It was also unclear whether the correct doctor was contacted when the patient's condition worsened.
Addressed to: Royal Sussex County Hospital
AI-generated concerns summaryThe Prison Service Instruction 64/2011's 'Risk Factors for Suicide' section does not include 'irrational behaviour, out of touch with reality,' which the coroner noted could indicate psychosis and necessitate closer monitoring. This gap may have hindered appropriate risk management and monitoring.
Addressed to: Ministry of Justice; National Offender Management Service
AI-generated concerns summaryThe coroner identified a lack of formal training in child mental health risk assessment, staff disregard for Force policies, and persistently low staffing levels. There were also concerns about unrecorded rationales for resource allocation decisions and unallocated welfare incidents, leading to delays.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe discharge procedure lacked robustness, with no documentary proof of calls to the Crisis Team or immediate written notice of discharge, leaving a high-risk patient without support.
Addressed to: Leicestershire Partnership NHS Trust; Priory Hospital, Cheadle
AI-generated concerns summaryPrison healthcare staff continued administering Digoxin despite hospital instructions to discontinue, a drug error arising from a breakdown in communication and failure to review discharge correspondence at the prison.
Addressed to: Her Majesty's Prison, Leeds; The Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified that medication continued to be administered in prison despite hospital advice to discontinue it, owing to a communication breakdown between the hospital and prison, and discharge correspondence not being immediately available or reviewed by prison healthcare staff.
Addressed to: Head of Healthcare, HMP Leeds; Medical Director, Leeds Teaching Hospitals, NHS Trust
AI-generated concerns summaryThe coroner identified that a chevron warning sign was missing due to prior accident damage, and noted concerns regarding the poor condition and substandard adhesion of the road surface at Stangrah Farm.
Addressed to: Highways Department, Cumbria County Council
AI-generated concerns summaryThose present in an emergency did not know how to operate the Suction Excavator to release a person, and Digsafe Excavations Ltd did not provide a second trained operator. There is also no specific HSE guidance on the use of Suction Excavation machines, required training, or the provision of a …
Addressed to: Digsafe Suction Excavations Limited; Health and Safety Executive
AI-generated concerns summaryThe coroner identified insufficient availability of in-patient mental health beds, leading to delays in Mental Health Act Assessments. These delays could result in individuals taking their own lives before assessment and bed provision.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Bristol Clinical Commissioning Group; Care Quality Commission
AI-generated concerns summaryThe coroner noted that a wooden access gate and fence to the railway line at Lower Farm Road offered little deterrence to access. Recommendations to replace this with a more significant fence have not been actioned.
Addressed to: Network Rail
AI-generated concerns summaryThe care plan for Mr Harris did not address his absconding risk, and this critical information was not effectively transferred to the hospital. Additionally, the hospital did not consider an emergency Deprivation of Liberty Safeguards (DOLS) application, and the DOLS application itself experienced significant processing delays.
Addressed to: Birmingham City Council; Kerria Court residential home; Sandwell and West Birmingham Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted insufficient consideration of potential physical effects from reported ingestion of foreign bodies and the lack of a clear treatment and observation plan, which might contribute to similar deaths.
Addressed to: Tees, Esk and Wear Valley
AI-generated concerns summaryThe coroner identified inadequate observation of a patient at risk of self-harm and frequent instances of patients leaving A&E before psychiatric assessment. It was also noted that a triage nurse was unaware of Mental Health Act holding powers.
Addressed to: North Middlesex University Hospital NHS Trust
AI-generated concerns summaryConcerns were raised regarding the GP referral procedure to the Community Mental Health Team, specifically the lack of an audit trail for faxed requests and inconsistent follow-up calls to confirm receipt. This meant the CMHT might be unaware of patient referrals.
Addressed to: Department of Health and Social Care; Endless Street Surgery
AI-generated concerns summaryThe coroner identified a lack of consistent assessment and discharge decisions, noting gaps in managing patients with capacity who decline care despite family concerns. The Serious Incident Report was also found to be incomplete.
Addressed to: Cornwall Partnership Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of formal mental capacity assessment and DoLS consideration both in the community and upon hospital admission. There was also insufficient communication between care providers, resulting in crucial patient information not being shared with the hospital.
Addressed to: Central Manchester University Hospitals NHS Foundation Trust; Manchester Mental Health and Social Care Trust; Regard Care