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 the absence of effective barriers to separate people from the canal where smoking was permitted, and that the canal offered no means of escape for anyone who fell in.
Addressed to: British Waterways; Canal and River Trust; Hilton Hotel
AI-generated concerns summaryThe coroner identified insufficient direct supervision during mealtimes for a resident with dementia, who choked after being given toast following a 17-hour period without food. Her care plan was also not updated despite a prior related incident.
Addressed to: Caring Homes Healthcare Group Limited; Cedar Care Home
AI-generated concerns summaryThe outcome of a review meeting was not signed off in writing by those in attendance and was not clearly communicated to the individual concerned.
Addressed to: North Essex Partnership University NHS Foundation
AI-generated concerns summaryDeficiencies in provision and protocols for urgent and emergency endoscopies and surgery were identified. Concerns also included staff compliance with the NEWS system, record-keeping, and criteria for doctor presence during critical patient transfers.
Addressed to: Calderdale Royal Hospital
AI-generated concerns summaryThe report identifies a risk from the absence of operator seat restraints in self-propelled sprayers, as operators can be thrown from the vehicle during an overturn. It suggests revising HSE guidance which indicates restraints may not be needed for these vehicles.
Addressed to: Bateman Engineering Ltd; Health and Safety Executive; the appropriate authority in Portugal
AI-generated concerns summaryThe coroner noted severe demand and staff shortages within the North East Ambulance Service division contributed to ambulance arrival delays, further impacted by road closures and diversions.
Addressed to: North East Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that non-correlating examination results were not further investigated with an ultrasound, leading to an undiagnosed breech presentation and preventing appropriate planning for delivery.
Addressed to: South Tees Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the patient's MRSA history not being established pre-surgery, and a lack of prophylactic medication. There was no post-operative wound care plan, insufficient surgical wound inspection, and inadequate documentation of wound status.
Addressed to: Medway NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies insufficient arrangements for constant poolside supervision at the hotel, noting concerns that reliance on CCTV monitored by reception staff with other duties and infrequent patrols may not ensure adequate visibility of the pool.
Addressed to: Dalmeny Hotal
AI-generated concerns summaryThe coroner noted insufficient monitoring of potassium levels every 8 hours following a diagnosis of severe hypokalaemia and a lack of adherence to the Trust's acute hypokalaemia management guidance.
Addressed to: Chesterfield Royal Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a policy or procedure for following up individuals discharged from one service to another, observing that a previously agreed action plan for this had not been implemented since 2015.
Addressed to: Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted insufficient dissemination of information to healthcare providers and implant manufacturers regarding how a specific toxin, linked to breast implant sepsis, can suppress signs of local inflammation.
Addressed to: Homerton University Hospital NHS Trust; Johnson and Johnson Medical Devices
AI-generated concerns summaryThe coroner noted gaps in police training regarding the tactical option of containment for subjects with suspected excited delirium. Additionally, restraint training did not include the risk of death from take-down procedures.
Addressed to: College of Policing; National Police Chiefs’ Council
AI-generated concerns summaryDeficiencies were noted in the Philips Respironics Trilogy 202 BIPAP machine's battery alert system and staff training on battery depletion. The ward also lacked an isolated power supply, a mains power failure alert system, and a functional crash bell.
Addressed to: Department of Health and Social Care; Phillips Healthcare; St Georges University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a protocol or guidance for Mental Health Nurses on when to refer a discharge decision to a doctor for patients who self-harmed, particularly those under a Community Treatment Order.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified insufficient mental health training and medical note review by reception staff, alongside deficiencies in the ACCT process. Further concerns included inadequate First Aid training and emergency response by prison staff, and limited weekend healthcare access for inmates.
Addressed to: NHS England; HMP Ranby; National Offender Management Service; Nottinghamshire Healthcare NHS Foundation Trust; The Care Quality Commission; The Prisons and Probation Ombudsman; Secretary of State for Health; Secretary of State for Justice
AI-generated concerns summaryThe coroner raised concerns regarding the robustness of the mental health screening pathway, noting that junior staff conduct initial screenings. There was also an identified need for consistent practice of this pathway across all equivalent teams within the Trust.
Addressed to: Southern Health NHS Foundation Trust
AI-generated concerns summaryStaff were not alerted by either Mrs Metcalfe's hand-held buzzer or her specialist bed alarm when she got out of bed, leading to her fall.
Addressed to: Rosedale Care Home
AI-generated concerns summaryThe coroner identified a lack of a nationally accepted guideline for airway assessment grading in neonatal practice and noted that neonatologists lacked clear criteria for identifying and communicating a potentially difficult airway to anaesthetists.
Addressed to: appropriate Royal Colleges; Department of Health and Social Care
AI-generated concerns summaryInsufficient detail in IAPT electronic records for medication and a risk assessment tool unable to reflect patient deterioration were identified. Additionally, there was a lack of practitioner recognition of increasing suicides in middle-aged males and socio-economic factors.
Addressed to: Rotherham, Doncaster and South Humber NHS Foundation Trust