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 highlights the need for an intermediate referral option between the existing '4-hour' and 'within 5-day' periods for urgent mental health service referrals, alongside effective management of this new category.
Addressed to: Sussex Partnership NHS Foundation Trust; West Sussex County Council
AI-generated concerns summaryThe coroner identified delays in A&E assessment due to staffing and an inoperable protocol. Concerns also included on-call consultants lacking updated patient deterioration information, leading to delayed decisions and issues with transfer communication.
Addressed to: Maidstone and Tunbridge Wells NHS Trust
AI-generated concerns summaryThe coroner identified fragmented service provision for patients with co-occurring substance misuse and mental health issues, with insufficient information sharing and joint working between providers. There is also a lack of understanding in primary care about accessing appropriate help.
Addressed to: Framework; CRI; NHS England; Nottinghamshire healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient recording of observations and interactions with psychiatric patients, noting some staff lacked understanding of record-keeping importance. Additionally, concerns were raised about non-contemporaneous notes made post-death without retrospective labelling.
Addressed to: Department of Health and Social Care; NHS England; Surrey and Borders Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that the bed could move from the wall because its inner wheels were not locked, and the locking mechanism was not easily accessible when the bed was against a wall. This poses a risk of recurrence for service users with this type of bed.
Addressed to: George Eliot Hospital NHS Trust; NHS England; Welsh Government
AI-generated concerns summaryThe coroner identified that the promulgation of good practice, detailed in a Root Cause Analysis, for the insertion and removal of central venous lines might reduce deaths from misplaced lines.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that carers were not required to log check times accurately, and the system for indicating DNACPR status (stickers/central notes) led to delays in resuscitation. Additionally, a lack of national standards meant the emergency resuscitation pack was missing key equipment.
Addressed to: Healthcare Management Solutions Ltd
AI-generated concerns summaryThe coroner raised concerns regarding the efficiency of missing persons searches, noting issues with the reliance on volunteer organisations for mapping and the absence of police-controlled stand-alone mapping systems and tracking devices for searchers.
Addressed to: Hampshire Constabulary Police; Police Crime Commissioner for Hampshire
AI-generated concerns summaryThe coroner noted the absence of signs or auditory warnings in lifts to indicate rear door opening, and that rear doors were not clearly marked or distinguishable from the interior.
Addressed to: Health and Safety Executive; Oadby and Wigston Borough Council; Sainsbury’s
AI-generated concerns summaryThe Royal Bolton Hospital's policy preventing A&E doctors from issuing standard prescriptions, coupled with limited hospital pharmacy opening hours, restricts patients' 24-hour access to essential medications. This gap in provision could contribute to future deaths.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryThe coroner noted the hospital lacked understanding in interpreting Legionella water sample results, leading to an erroneous conclusion about the infection source. There was no established procedure for investigating Legionella outbreaks.
Addressed to: Bath and North East Somerset Clinical Commissioning Group; Care Quality Commission; Royal United Hospitals Bath NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the long wait times for urgent 'hot foot' clinic referrals, which led to patient deterioration. The coroner noted the need for a review of patient prioritisation, resource allocation, and a standardised referral process with clearer guidance for community nurses.
Addressed to: North Somerset Clinical Commissioning Group; North Somerset Community Partnership; Weston Area Health NHS Trust
AI-generated concerns summaryThe NHS Trust does not have facilities for routine CT scans on weekends, and the urgent scan procedure can cause delays, as a required scan was postponed until after the weekend.
Addressed to: Maidstone and Tonbridge Wells NHS Trust
AI-generated concerns summaryThe coroner noted a need to review tinzaparin prescribing practices and blood level monitoring, alongside reiterating the importance of monitoring creatinine clearance according to Health Board policy.
Addressed to: West Wales General Hospital
AI-generated concerns summaryThe coroner noted fire officers concluded dust on light fittings caused smoke and a burning smell without positive evidence, recommending national dissemination of learning on this risk.
Addressed to: Avon Fire and Rescue Services; Chief Fire & Rescue Adviser
AI-generated concerns summaryNo specific concerns text was provided to summarise.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that attending police officers were unable to assess a seriously injured person or commence basic life support. A review of basic life support training for all police officers acting as first responders was suggested.
Addressed to: Bedfordshire Police
AI-generated concerns summaryThe report identifies that Level 2 observations were not conducted as prescribed, fluid balance charts were incomplete, and patient bedrooms lacked call bells. Concerns were also raised that staff may not adequately appreciate signs of physical illness.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryThe coroner identified a lack of adequate lighting at the harbour wall's end, obscuring its boundary and making the single, distant lifebelt nearly invisible.
Addressed to: Square Sail
AI-generated concerns summaryBarts and the London might consider face-to-face meetings for significant academic decisions instead of email. East London Trust staff need clarity on patient confidentiality, distinguishing between receiving information from third parties and disclosing patient details.
Addressed to: Barts and London School of Medicine and Dentistry; East London NHS Trust; Queen Mary University of London