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 the need for a full understanding of the legal status of individuals in care homes, as a lack of clarity could impact their care and treatment.
Addressed to: Kingsley Care Home; Timperley Care Home
AI-generated concerns summaryThe coroner noted incomplete history taking and a failure to report obvious symptoms like swollen tongue and facial swelling to treating doctors. Concerns were also raised that basic blood tests for infection/sepsis were not obtained, affecting patient management.
Addressed to: University of Manchester NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient neurologists nationally, contributing to delays in specialist neurological input, including a lack of out-of-hours on-call neurologists at the admitting hospital and lengthy outpatient waiting times.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryA patient's mental health referral was sent to the incorrect team and experienced an unexplained delay, while communication regarding the assessment outcome was not sent to the GP in a timely manner.
Addressed to: Black Country Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of staff training in patient feeding mechanisms, techniques, and associated risks, including no refresher training. Additionally, no training was available for family members on safe feeding practices.
Addressed to: BUPA; Mill View Nursing Home; Right Honourable Jeremy Hunt MP
AI-generated concerns summaryThe hospital observation policy was not consistently followed, with staff failing to adequately monitor a patient and check their well-being. There was also a delay in commencing CPR after the patient was found unresponsive.
Addressed to: Broadmoor Hospital
AI-generated concerns summaryThe coroner noted insufficient first aid training for all prison officers, questioned the effectiveness of the prison's anti-bullying policy, and identified a lack of referral of the deceased's mental health and self-harm history to a Multi-Agency Safeguarding Hub (MASH) meeting.
Addressed to: HMP Stoke Heath; Ministry of Justice
AI-generated concerns summaryDrivers exiting the roundabout have no prior warning of the pedestrian/cycle crossing due to limited visibility and misleading features, with a review of warning signs and design recommended. Carriageway markings exiting the roundabout are also obscured by resurfacing work and debris, requiring attention.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted that night-time checks lacked specific details on the patient's condition, only recording times, and that there was no clear procedure for care assistants to escalate health concerns.
Addressed to: Belong Village; Care Quality Commission
AI-generated concerns summaryThe coroner noted the non-retention of the placenta after a baby's death hindered the pathologist's investigation into potential causes like infection or umbilical cord issues. It was recommended that placentas be retained in similar circumstances.
Addressed to: York Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the mortality risk associated with Mini Tracheostomy Procedures performed outside theatre or without ultrasound guidance, and the lack of national guidance for these procedures.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted an ambulance response time of nearly 2 hours and 40 minutes for an Amber 2 call, significantly exceeding the 20-minute target. Concerns were raised about the lack of communication with the patient's family and insufficient planning for maintaining services during periods of high call volume.
Addressed to: Health Inspectorate Wales; Minister for Health and Social Services; Welsh Ambulance Services NHS Trust
AI-generated concerns summaryThe A470, a challenging road with a history of serious collisions, lacks an advanced warning sign for an approaching left bend, which the coroner recorded would assist motorists in reducing risk.
Addressed to: Powys County Council
AI-generated concerns summaryAn advanced warning sign for a challenging left bend on the A470 is absent, and a forensic collision investigator indicated such a sign would reduce the risk of future collisions.
Addressed to: Powys County Council
AI-generated concerns summaryThe coroner noted a challenging stretch of the A470 road, with a history of serious collisions, and identified the need for an advanced warning sign for an approaching left bend to mitigate future risks.
Addressed to: Powys County Council
AI-generated concerns summaryThe coroner noted the A470 is a challenging stretch of road with a history of serious collisions. An advanced warning sign for an approaching left bend would significantly assist motorists and help reduce the risk of similar fatalities.
Addressed to: Powys County Council
AI-generated concerns summaryTechnical difficulties transmitting CT scans between hospitals led to delays in treatment planning. The coroner noted these issues are ongoing, risking delays in lifesaving treatment for patients with urgent conditions.
Addressed to: Sandwell and West Birmingham NHS Trust; University Hospital Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues with life-saving equipment, including a lack of suction equipment, a defective ambubag, and an inoperable defibrillator. There were also substantial delays in the arrival of emergency ambulances.
Addressed to: Carralejo Fuerteventura; Foreign and Commonwealth Office
AI-generated concerns summaryThe coroner noted issues with oxygen administration, including an incorrect flow rate and improper patient positioning. There was also a lack of staff understanding regarding emergency oxygen use and no evidence of relevant training for the Clinical Manager.
Addressed to: Acorn Lodge Care Home
AI-generated concerns summaryThe coroner noted that ward staff did not directly call 999, risking call disconnections during transfers, and that staff providing information to ambulance services might lack up-to-date patient status. Additionally, there was no one immediately available to escort paramedics upon their arrival at reception, causing delay.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust