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 raises concerns about insufficient awareness among caravan users and residents regarding the importance of fitting and maintaining smoke detectors in mobile and static caravans.
Addressed to: Surrey Fire and Rescue Service; Caravan Club; Showmen’s Guild of Great Britain
AI-generated concerns summaryThe concerns text for this report is incomplete, so specific issues cannot be identified.
Addressed to: East Lancashire Healthcare NHS Trust
AI-generated concerns summaryThe coroner highlighted a lack of comprehensive mental health assessment and proper record-keeping regarding Mr Blair's medication upon prison reception. Also noted were delays in emergency response, including communication of ambulance gate location and difficulties in accessing resuscitation equipment.
Addressed to: Care UK; HMP Pentonville; London Ambulance Services NHS Trust; National Offender Management Service
AI-generated concerns summaryHealthcare staff did not recognise Mrs Sangare's need for immediate cardiopulmonary resuscitation, and did not respond immediately to an activated alarm, assuming it was a behavioural issue. There was also limited telephone access for agency staff.
Addressed to: Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues with police decision-making in leaving a vulnerable person before an ambulance arrived. Concerns also included a significant ambulance response delay and the inadequacy of call coding algorithms to assign a Red response for critical injuries.
Addressed to: Department of Health and Social Care; Greater Manchester Police; NHS England; North West Ambulance Service
AI-generated concerns summaryThe coroner noted the absence of working suction equipment on the ward during a cardiac arrest and identified a lack of a structured checking procedure to ensure its functionality and properly charged batteries.
Addressed to: George Eliot Hospital
AI-generated concerns summaryThe coroner noted Mrs Cordy was placed in a care home with 2-hourly checks despite needing constant supervision. No specific falls risk assessment was undertaken despite a falls history, and only a floor mattress was provided for prevention.
Addressed to: Northampton General Hospital; Templemore Care Home
AI-generated concerns summaryThe coroner noted an absence of Senior Consultant review and locum cover, insufficient daily review of test results, and inconsistent medical records that led to a lack of clarity regarding the care plan.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that the SASH document is not consistently identifiable to all relevant staff during the reception process, and noted insufficient training for officers in ACCT processes.
Addressed to: HMP Winchester
AI-generated concerns summaryThe coroner identified an acutely unwell patient was admitted to a private hospital without HDU/ITU facilities or staff trained for critical care. Concerns were also raised regarding the chest drain insertion's non-adherence to best practice, lack of real-time ultrasound guidance, and insufficient post-procedure checks.
Addressed to: BMI Hospitals; Care Quality Commission; General Medical Council; Royal College of Radiologists; Royal Surrey County Hospital
AI-generated concerns summaryConcerns were raised regarding the failure to issue a Code Blue in accordance with policy, a lack of understanding of its implications for summoning an ambulance, and not considering or using an available defibrillator when appropriate.
Addressed to: HMP Rochester
AI-generated concerns summaryIllegible clinical records and incomplete documentation were identified as creating a serious risk of communication breakdown and misinformation in a patient's care pathway.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryConcerns include multiple fatalities at a road junction since 2010, with proposed safety work lacking funding approval or a start date. The coroner also notes concerns about the speed limit and warning signs on Station Road.
Addressed to: A-ONE+; Highways England; Nottinghamshire County Council
AI-generated concerns summaryThe coroner noted that the Orwell Bridge's low concrete wall provides the only barrier preventing falls, with nothing in place to physically deter or make it difficult to climb onto the wall, which offers no hand or footholds if someone slips.
Addressed to: Suffolk County Council Highway Department
AI-generated concerns summaryThe coroner noted that X-rays on admission are not immediately reviewed by a radiologist, leading to delays in identifying injuries due to a national shortage of radiologists. This practice creates a foreseeable risk of further deaths and fails to meet national targets for urgent X-ray reporting.
Addressed to: Department of Health and Social Care; University Hospitals of Morecambe Bay NHS Trust
AI-generated concerns summaryThe concerns text for this report is incomplete, so specific issues cannot be identified.
Addressed to: East Lancashire Healthcare NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding inadequate staff training and a failure to comply with the duty of Candour. It was also noted that corporate pharmacy guidelines contradicted NICE guidance and nursing staff did not alert consultants to known risk factors.
Addressed to: BMI Health Care
AI-generated concerns summaryThe coroner identified an over-reliance on maternal observations in obstetric emergencies, potentially overlooking fetal distress, and noted significant ambulance resource delays due to meal break management and lack of 'open mic' reports.
Addressed to: Chair of Association of Ambulance Chief Executives; East Midlands Ambulance Service NHS Trust; NHS Hardwick Clinical Commissioning Group; Sustainable Improvement Team, NHS England
AI-generated concerns summaryThe coroner identified the absence of an acute mental health facility in Powys, leading to patients being moved long distances and a resulting lack of continuity of treatment. This situation may negatively impact patient engagement with mental health services.
Addressed to: Department of Health and Social Care; Powys Teaching Health Board
AI-generated concerns summaryThe coroner identified that a healthcare assistant did not adhere to the Trust's observation policy for a patient with mental health illness, leading to an unwitnessed fall. There was also a significant lack of documentation regarding patient observations, contrary to Trust policy and national guidance.
Addressed to: Brighton and Sussex University Hospitals NHS Trust