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 consultant psychiatrist did not communicate clear clinical expectations to Jack's family before discharge, including what recurrence of psychotic symptoms would signify and when to seek urgent professional help. This left the family unaware of when immediate re-hospitalisation might be necessary.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about road conditions, including a broken and crumbling road edge with a pothole and leaf/soil debris, recommending a review and consideration of remedial action at the location.
Addressed to: Bradford Metropolitan Borough Council
AI-generated concerns summaryConcerns were raised about staff competence and training in the Acute Assessment Unit regarding NEW Score use and communication. Senior staff did not attend when monitoring equipment alarmed continuously, and alternate monitoring forms were not considered.
Addressed to: North Middlesex Hospital
AI-generated concerns summaryHealthcare complex case planning lacked robustness and updates, with multi-disciplinary team meetings being informal and not providing ready access to all relevant risk assessment information. Services also failed to adequately investigate an earlier overdose event, which missed a safeguarding and learning opportunity.
Addressed to: Leicestershire Partnership NHS Trust; Northamptonshire Healthcare NHS Foundation Trust; East Midlands Ambulance Service NHS Trust; HMP Gartree
AI-generated concerns summaryThe coroner noted the A66 includes single carriageway sections where fatal head-on collisions occurred. The report states the road should be dual carriageway throughout to prevent avoidable deaths.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner expressed concern that the A66, a busy arterial route with sections of winding country road, should be a dual carriageway throughout to prevent future head-on collisions and avoidable deaths.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of provision for prisoners with complex health needs and insufficient staff for segregation unit regimes. Additionally, concerns were raised about an unclear documentary tool for assessing fitness for segregation and healthcare staff's awareness of physical symptoms masked by mental health issues.
Addressed to: HMP Nottingham; National Offender Management Service; NHS England; Nottingham Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted that Pentobarbital, a drug commonly used in suicides, is classified under Schedule 3 of the Misuse of Drugs Regulations 2001, which has less strict controls than Schedule 2, impacting access.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that windows in service user areas at Morlais Ward are not ligature-free, and despite plans for this work following a death, it has not yet been undertaken.
Addressed to: West Wales General Hospital
AI-generated concerns summaryA high-risk service user lacked a smoke detector in their bedroom, and social workers had not considered this despite known fire risks and previous fire brigade call-outs.
Addressed to: London Borough of Hackney
AI-generated concerns summaryVERONICA HAMILTON-DEELEY, LLB_.
Addressed to: Brighton Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified that overgrown plant growth on a central reservation dangerously restricted a driver's view at a junction, noting that regular maintenance is needed and similar risks may be present at other junctions on the road.
Addressed to: Hertfordshire County Council
AI-generated concerns summaryThe coroner raises concerns about the ready availability of toxic helium gas online and on the high street. The report requests action to regulate its sale, canister size, and valve design to prevent misuse.
Addressed to: Right Honourable Theresa May MP
AI-generated concerns summaryThe coroner noted that the GP did not receive a discharge letter from Wythenshawe Hospital, and the patient was not provided with prescribed antibiotics upon discharge.
Addressed to: South Manchester University Hospital NHS Trust
AI-generated concerns summaryBedside observation charts were unhelpful, nursing staff lacked training on calling critical outreach teams, and there was insufficient escalation of clinical concerns between staff. Telephonic communication and blood administration systems also presented problems.
Addressed to: Croydon University Hospital and NHS Trust
AI-generated concerns summaryThe report describes a lack of understanding regarding the rare hyperammonaemia syndrome, an adverse consequence of gastric bypass surgery, and its symptoms.
Addressed to: British Obesity and Metabolic Surgery Society
AI-generated concerns summaryThe coroner identified gaps in record-keeping for GP advice in multi-disciplinary notes and a lack of a safe system for documenting and confirming telephone advice. Conflicting information between providers also delayed out-of-hours pathology testing for community patients.
Addressed to: British Medical Association; Care UK; Epsom and St Helier University Hospitals NHS Trust; Linden House Surgery; Ashlea Medical Practice; Surrey Downs Clinical Commissioning Group
AI-generated concerns summaryThe current NHS Pathways triage system used by the Ambulance Trust lacks a specific tool to recognise agonal or inadequate breathing, which was present in a previous system. Concerns about this omission have been raised nationally since 2014, but no action appears to have been taken.
Addressed to: NHS Pathways
AI-generated concerns summaryThe coroner noted that South West Trains had not responded to a British Transport Police report recommending safety measures for a footbridge at Liss Station, which were intended to reduce the risk of persons climbing over the parapet.
Addressed to: South West Trains
AI-generated concerns summaryThe coroner notes a lack of awareness regarding the flammability of paraffin-based E45 cream among carers and the deceased, attributed to insufficient communication from the GP and an absence of fire hazard warnings on the product packaging and prescription.
Addressed to: Commissioning and Operations, Centra Midlands NHS; Fire Officers Association; Reckitt Benckisher Healthcare (UK) Ltd