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 local authority delayed in acting on an urgent GP referral for an assessment of Mr. Embra, resulting in approximately a one-week wait before a social worker visit.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner noted unsatisfactory surgical notes for a previous operation, which lacked specific details regarding the ventricular septal defect, tricuspid valve, and techniques used. This deficiency could deprive future surgeons of vital information needed for subsequent procedures.
Addressed to: St James’s University Hospital
AI-generated concerns summaryConcerns included a lack of review for discharge decisions despite changes in patient presentation, a disjointed discharge process, and poor record keeping. The report also identified the absence of an inpatient clinical psychologist service.
Addressed to: Pennine Care NHS Trust; Rochdale, Heywood and Middleton Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that pharmacists in general practices continue to snip tablets from unit dose packs into multi-dose compliance aids, a practice contrary to professional body advice.
Addressed to: Dispensing Doctors Association; Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner noted poor record keeping, including missing appointment records, and concerns about a policy of not seeing patients who are more than ten minutes late, even with known medical history.
Addressed to: Black Country Family Practice
AI-generated concerns summaryWard staff did not recognise the side effects of opiate medication on an orthogeriatric patient, and there was no clear, easily accessible guidance available to staff on the risks and side effects of opiate medications for this patient group.
Addressed to: Royal London Hospital
AI-generated concerns summarySafety recommendations from a British Transport Police report, aimed at creating a safer environment at the bridge and restricting public access to the railway, had not been implemented by the time of the inquest.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted concerns about the lack of a required specification for digital record keeping and scans in regional maternity services, leading to reliance on paper notes for continuity of care between providers. This inefficiency could impact patient referrals and safe admissions to maternity units.
Addressed to: Department for Health; NHS England
AI-generated concerns summaryThe coroner noted several deaths involving self-inflicted firearm wounds from unlicensed weapons, which were not securely stored and available for impulsive use. A suggestion was made to publicise the practice that surrendering an unlicensed firearm does not usually lead to prosecution.
Addressed to: Lincolnshire Police
AI-generated concerns summaryThe coroner raises concerns about insufficient control over medication administration and monitoring at Alexandra Court Care Home, noting that residents may receive incorrect amounts of prescribed medication.
Addressed to: Cuerden care Homes
AI-generated concerns summaryThe coroner raised concerns about a junior doctor's misinterpretation of an abnormal ECG trace and Mrs Rollason's subsequent discharge without further observation, identifying this as a missed opportunity for basic medical care and investigation.
Addressed to: Royal Wolverhampton, New Cross Hospital
AI-generated concerns summaryThe coroner noted concerns about the Status Epilepticus protocol's dissemination, inadequate medical notes, and care escalation understanding. The legal authority for detaining an agitated patient without proper authorisation was also questioned.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryInsufficient doctor and nurse staffing led to significant delays in antibiotic administration and patient review. The report also notes issues with adherence to escalation guidelines, clarity of pharmacy medication details, and immediate shredding of handover sheets.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryAlternative hospital transport options were not discussed with the friend who called 111, and the potentially grave consequences of a vomiting illness in a person with diabetes were not explained to him.
Addressed to: London Ambulance Services NHS Trust; London Central & West Unscheduled Care Collaborative; St Charles Hospital
AI-generated concerns summaryThe intermediate care ward had inadequate planning, unclear care standards, and insufficient staffing. There was no proper handover from the hospital regarding patient needs, and physiotherapy was significantly delayed.
Addressed to: L and M Healthcare; Tameside Hospital NHS Trust
AI-generated concerns summaryThe deceased's daughter was unaware of her designated role as a protective factor in her mother's care plan, which limited her ability to recognise signs of mental health relapse.
Addressed to: Bampton Surgery
AI-generated concerns summaryThe coroner identified issues with staff not following care plans or being aware of policies, difficulties escalating patient care and obtaining urgent CT scans, and insufficient weekend staffing levels.
Addressed to: Ashford and St Peter’s Hospital Trust
AI-generated concerns summaryThe report raises concerns that were not detailed in the excerpt.
Addressed to: Brighton and Hove Clinical Commissioning Group; Brighton and Hove Integrated Care Service; Brighton and Sussex University Hospital Trust
AI-generated concerns summaryThe coroner noted insufficient communication with a patient's partner regarding the basis for weekend leave and a lack of routine family feedback post-leave. There were also concerns about confusion over medical authorisation for informal patient leave and substandard nursing documentation.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe report raises concerns that were not detailed in the excerpt.
Addressed to: East Lancashire Healthcare NHS Trust