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 a lack of an identified lead professional for individuals, particularly children transitioning to adult services, being cared for by numerous agencies, which can lead to communication breakdowns.
Addressed to: Gloucestershire Clinical Commissioning Group; Gloucestershire County Council
AI-generated concerns summaryConcerns were raised regarding the absence of a standard question to identify previous patient contacts, the selection of incorrect questionnaires by non-medically qualified staff, and no review of earlier calls within NHS Direct.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted concerns regarding delays in Mr Nute's ambulance attendance and transfer, inappropriate 999 call triage, and insufficient communication to police about a road traffic accident, leading to poor scene management.
Addressed to: Devon and Cornwall Police; South Western Ambulance Service
AI-generated concerns summaryConcerns were raised regarding the adequacy of the platform barrier's security and the frequency of security checks. The coroner also questioned whether the individual's hour-long presence asleep on the platform was identified as a safety concern by station staff.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted the poor state of a railway crossing point, identifying a potential tripping hazard due to a section standing proud of the metal track bed.
Addressed to: Great Western Railway
AI-generated concerns summaryThe coroner noted a three-hour delay in calling an ambulance for a person who had been hit, despite the care plan indicating immediate transfer to the emergency department for significant injury. This delay might have been contributory to the cause of death.
Addressed to: Borough Care Ltd
AI-generated concerns summaryThe coroner noted a lack of effective investigation or safeguarding referral regarding possible pushing, despite medical records, and insufficient evidence of mandated 15-minute observations. There were also insufficient night staff to meet residents' needs on the dementia unit.
Addressed to: Ideal Care Home Ltd
AI-generated concerns summaryThe coroner noted insufficient pain score recording at triage, after analgesia, and prior to discharge for a patient presenting in severe pain. Concerns were also raised about the lack of systematic assessment of pain response and inadequate pain audits for severe pain in A&E.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner noted a lack of evidence that staff checked daily if all GP messages had been countersigned as received or acted upon by the GPs.
Addressed to: Clevedon Medical Centre
AI-generated concerns summaryThe report identified issues with frequent patient transfers, poor medical record-keeping, and an inconsistent method for anti-coagulant dosing. Concerns were also raised about shortages of trained nurses and essential equipment, leading to surgical delays.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a build-up of wet soil and sandy deposits on the side of the A25 Sheer Road, which may present a risk to drivers. Consideration should be given to minimising this contamination and alerting road users.
Addressed to: Surrey County Council
AI-generated concerns summaryThe coroner noted insufficient discharge counselling for a patient on Apixaban, concerns about 111 advisor training and algorithm imprecision, and a breakdown in IC24 callback procedures. A joint Root Cause Analysis has not yet occurred.
Addressed to: IC24; SECAMB; Western Sussex Hospital NHS Trust
AI-generated concerns summaryThe coroner identified limited non-hospital respite care options for mentally ill people in the community, noting the withdrawal of the beneficial Dove House facility without alternative provision. It was recorded that if such an option had been available, it might have prevented the death and could prevent future self-inflicted deaths.
Addressed to: Department of Health and Social Care; South London and Maudesley NHS Trust
AI-generated concerns summaryThe coroner identified a need for a clear process when NELFT staff require mental health care but are hesitant to share information internally, including prompt referral to a different Trust and adequate safety plans on discharge.
Addressed to: North East London Foundation Trust
AI-generated concerns summaryThe coroner identified a missed opportunity to investigate abnormal ECG and tachycardia, alongside failures in recording and transmitting medical information, and a lack of consideration for the significance of Diclofenac medication.
Addressed to: Walsall Healthcare NHS Trust
AI-generated concerns summaryThe report highlights inadequate mental health care, incomplete care planning, and significant communication deficits during multiple prison transfers, which led to a failure to recognise a relapse in the deceased's condition and properly observe ACCT procedures.
Addressed to: Department for Health; NHS England
AI-generated concerns summaryAn observed or reported epileptic event involving a Morrison's employee at work was not recorded by the employer.
Addressed to: DWF LLP; W M Morrisons PLC
AI-generated concerns summaryThere is no robust system to ensure that summary medical information from electronic records is conveyed to A&E departments when inmates are referred, which risks delaying diagnosis for other patients.
Addressed to: HMP Lindholme
AI-generated concerns summaryThe coroner noted no staff reported a resident's injury and there was a 12-hour delay in escalating her allegations of being harmed by a staff member.
Addressed to: ADL PLC; Care Quality Commission
AI-generated concerns summaryThe coroner noted a paediatric doctor's decision to extubate was a mistake, and earlier use of a CO2 monitor and consultant consultation would have been beneficial. There were also delays contacting a tertiary unit and an inadequate handover for the baby's arrival.
Addressed to: Care Quality Commission; Walsall Healthcare NHS Trust