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 consultant referrals were routinely handled by middle-grade doctors first, and liver function tests were declined due to demand management without a clear mechanism for staff to override this policy for clinical necessity.
Addressed to: Hywel Dda University Health Board
AI-generated concerns summaryThe coroner notes that advice and guidance for insulin pumps do not adequately highlight dangers of misuse, and diabetic patient education lacks focus on the rapid life-threatening nature of unmanaged hyperglycaemia.
Addressed to: Medicines and Healthcare Products Regulatory Agency; NHS England; NHS Wales; Roche Diagnostics Limited
AI-generated concerns summaryThe coroner raised concerns about the availability and use of undetected, damaged, and defective oxygen flow meters, posing a patient safety risk. Further issues included staff not detecting audible damage and insufficient dissemination of incident information beyond the Trust.
Addressed to: Medicines and Healthcare Products Regulatory Agency; Patient Safety Lead, County Durham and Darlington NHS Foundation Trust
Addressed to: Care UK; HMP Pentonville
AI-generated concerns summaryThe coroner identified the absence of a falls prevention care plan and incomplete post-fall nursing assessments and neurological observations. There were also concerns about unclear nurse responsibility and delayed communication of the fall to the consultant.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner identified a lack of action by Next Stage staff following overdose disclosures, insufficient follow-up with mental health services, and inadequate staff training. Concerns also relate to the mental health trust's unclear guidance for managing such disclosures.
Addressed to: 5 Boroughs Partnership NHS Foundation Trust, Warrington; Next Stage
AI-generated concerns summaryThe coroner noted insufficient staff resources led to missed checks for service users, and staff lacked knowledge on how to obtain an outside telephone line for emergency calls, causing a delay.
Addressed to: Independence Homes Limited
AI-generated concerns summaryThe coroner noted that pedestrians commonly cross from the wrong side of the pelican crossing on Dragon Street, leading to near misses. The report suggests installing railings to prevent this dangerous practice.
Addressed to: Department for Transport; Hampshire County Council
AI-generated concerns summaryThe coroner identified that carers lack specific training on how to manage unusual situations, such as adjusting environmental controls like heaters for clients, and recommended including such scenarios in future training.
Addressed to: Sheffield City Council
AI-generated concerns summaryThe coroner identified concerns regarding the inadequate number and lack of medical training of lifeguards, alongside communication difficulties, and the uncommunicated one-hour lunch break when lifeguards were off duty.
Addressed to: British Travel Agents
AI-generated concerns summaryThe coroner noted a lack of acute mental health inpatient beds, which meant vulnerable individuals received community care with limited resources. There was also no formal risk assessment concerning the deceased's access to medication despite her repeated statements about ending her life by overdose.
Addressed to: Birmingham and Solihull Mental Health Trust; Care Quality Commission; NHS England: Department of Health
AI-generated concerns summaryThe coroner raised concerns about the absence of an effective system for transmitting all information relevant to a detained person's self-harm risk or mental health, as observations recorded in police logs were not formally passed on.
Addressed to: METROPOLITAN POLICE SERVICE
AI-generated concerns summaryThe coroner identified delays in taking and testing blood samples from prisoners at HMP Dovegate, asking what actions can be taken to improve this situation at the prison and potentially others.
Addressed to: Care UK
AI-generated concerns summaryThe coroner noted incomplete, inconsistent, or conflicting patient records, consultations, clinical decisions, and discharge records. The hospital's draft Significant Clinical Incident Investigation report also contained factual assumptions that conflicted with documentary evidence, impacting the learning process.
Addressed to: BMI The Shelburne Hospital
AI-generated concerns summaryThe winter maintenance policy and decision-making process did not account for extreme local or "microclimatic" road conditions. There has been no formal review or learning sharing following the incident.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner highlighted gaps in call handler training concerning contacting resident managers after medical emergencies and the process for sharing information with other agencies. Protocols for escalating non-responses from emergency call system users also require attention.
Addressed to: Tunstall Response
AI-generated concerns summaryThe coroner noted that an undetected foreign body airway obstruction could inhibit the use of a supraglottic airway (SGA). Requiring a laryngoscopy before SGA use could identify such obstructions, a practice expected to become protocol.
Addressed to: Resuscitation Council (UK)
AI-generated concerns summaryThe coroner raised concerns regarding the effectiveness of hospital protocols and guidelines for identifying ecstasy toxicity risks and symptoms, and the appropriateness of clinical protocols for initial intervention and patient monitoring.
Addressed to: St Marien Hospital Trust
AI-generated concerns summaryA biopsy report form for Unilabs had insufficient room for a consultant gastroenterologist to fully complete it. The coroner suggested forms could be expanded or provision made for an addendum.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that weekend on-call staffing levels were insufficient for the workload, potentially impacting patient care, and suggested a review. There were also inaccuracies in MEWS tool scoring, indicating a need for refresher training as its use was not clearly understood.
Addressed to: Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust