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 inadequate ventilation, lack of suction, and no oxygen provided for 8 minutes following a collapse in a GP surgery, raising concerns about the level of expertise and equipment for resuscitation in such practices.
Addressed to: Birmingham Cross City Clinical Commissioning Group; NHS England; Wychall Lane Surgery
AI-generated concerns summaryThe coroner noted concerns regarding junior doctors performing a non-standard practice (manually pushing back the cervix) without consultant knowledge, and the inadequate process for obtaining informed consent from women in labour. These issues were not identified by the Trust's Root Cause Analysis.
Addressed to: St Richard’s Hospital; Western Sussex Hospital NHS Trust
AI-generated concerns summaryThe coroner noted the deceased's death was linked to a drain procedure and that a pre-procedure scan might have reduced this risk. Further consideration of related policy and guidance is needed, despite a lack of local support for changes.
Addressed to: County Durham and Darlington NHS Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a practice where nursing staff conducted first post-operative reviews and discharges without adequate medical oversight, leading to a patient presenting unwell not being seen by a doctor.
Addressed to: South Manchester University Hospital NHS Trust
AI-generated concerns summaryThe medical centre continued prescribing a drug in error after a request to stop it, because there was no mechanism to record the reasons for discontinuing medication in clinical records. This practice may be replicated in other GP practices.
Addressed to: Heaton Moor Medical Centre; NHS England
AI-generated concerns summaryCommunication broke down between the anti-coagulation clinic, the GP, and the care home regarding a resident's new GP details. Additionally, the General Practitioner did not consider the Medication Administration Record held by the home during new resident reviews, indicating a lack of a system for medication approval.
Addressed to: Alexander Court Care Central
AI-generated concerns summaryThe coroner noted the absence of regular checks on smoke and heat detectors in the property. The report called for a review of existing arrangements for maintaining and carrying out periodic checks on these devices.
Addressed to: Incommunities
AI-generated concerns summaryThe coroner noted that checks for foreign convictions are not mandatory across all UK police forces or consistently undertaken for UK nationals. Concerns were raised regarding the need for robust international data sharing on serious convictions and contingency planning for intelligence access post-Brexit.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified that the on/off control-switch for the mains powered alarm system was unprotected and could be switched off. It was noted that this control could easily be secured, despite current regulations not requiring it to be inaccessible.
Addressed to: Home Office; Secretary for Communities and Local Government
AI-generated concerns summaryThe coroner noted several missed observations and predictable 15-minute observation intervals for Mr Williams. There was also an inappropriate delay in opening his cell door, indicating a need for clear guidance and training for prison officers in such situations.
Addressed to: HMP Leicester
AI-generated concerns summaryThe coroner noted a discrepancy between police officers' assessment of a situation and the jury's determination that it constituted a police pursuit, implying non-compliance with Metropolitan Police Service procedures for seeking authorisation.
Addressed to: Metropolitan Police
AI-generated concerns summaryThe coroner noted concerns regarding the continued use of fluticasone in patients like Mr Pearson, where it presented an increased risk of pneumonia without corresponding benefits, and suggested a review of its use.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryNo specific concerns were detailed in the provided text.
Addressed to: Highway and Transport Wiltshire Council
AI-generated concerns summaryThe coroner identified a practice of writing discharge summaries in advance, which led to a patient being discharged prematurely before all necessary test results, including a second troponin, were available.
Addressed to: Heart of England NHS Foundation Trust; NHS England
AI-generated concerns summaryConcerns were raised regarding the categorisation of violent incidents by call handlers, the lack of formalised handover procedures and training for controllers, and the absence of an alert feature in the STORM computer system for unauthorised deferrals.
Addressed to: Chief Constable of Warwickshire Police
AI-generated concerns summaryThe coroner noted the ongoing lack of routine national GBS screening and prophylactic antibiotics. At the Trust, concerns included inadequate communication, non-adherence to protocols, insufficient monitoring for deterioration, lack of escalation to senior clinicians, and inadequate preceptorship for midwives.
Addressed to: Department of Health and Social Care; N.I.C.E; Pennine Acute Hospitals NHS Trust; Royal College of Obstetricians; Royal College of Paediatricians
AI-generated concerns summaryInsufficient or absent ACCT training for healthcare and prison staff meant mandatory provisions of the ACCT process were not being adhered to. This indicated a clear training need within the system.
Addressed to: G4S; National Offender Management Service; NHS England; Spectrum Community Health
AI-generated concerns summaryA penicillin-based antibiotic was prescribed and administered despite a GP referral letter stating a penicillin allergy. Concerns were raised about the deletion of allergy information from the patient's record and the insufficient verification of allergy status, particularly given the patient's cognitive impairment.
Addressed to: Central Manchester University Hospitals NHS Foundation Trust
AI-generated concerns summaryHostel staff lacked specific training on monitoring and safeguarding residents found appearing to have taken illicit drugs, with existing training not covering ongoing observation after a resident is put to bed.
Addressed to: Wallich Centre
AI-generated concerns summaryThe coroner identified inadequate record-keeping for radiology procedures, a lack of clear diagnostic pathways, and insufficient staff training to recognise serious conditions. Poor communication among staff and with the family was also noted.
Addressed to: Tameside Hospital NHS Foundation Trust