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 a lack of liaison between University College Hospital and Princess Alexandra Hospital to formulate an agreed delivery plan for a baby with identified heart anomalies. There is a need to review the system between tertiary and local hospitals for these cases.
Addressed to: Princess Alexandra Hospital NHS Trust
AI-generated concerns summaryThe coroner noted an inadequate system for ensuring urgent diagnostic tests, such as x-rays and ultrasounds, are performed without delay, particularly for patients admitted at weekends.
Addressed to: Bedford Hospital NHS Trust
AI-generated concerns summaryThe coroner identified significant confusion and uncertainty regarding policies for transferring patients with gastrointestinal bleeding within the Trust. Senior staff at Bassetlaw Hospital were also unaware of the new Doncaster Hospital service's operational details, particularly out of hours.
Addressed to: Doncaster and Bassetlaw Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner identified poor communication with parents and between staff, insufficient paediatric sepsis protocols, and a lack of guidance for communicating with disabled children. Inaccurate observation charts and poor record-keeping were also noted.
Addressed to: Doncaster and Bassetlaw NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of continuity of care at the GP practice and suggested a review of "Red Flag" identification for children. Concerns were also raised regarding the hospital's policy for reviewing GP medical records during young children's admissions.
Addressed to: Lockfield Surgery; New Cross Hospital
AI-generated concerns summaryThe coroner noted that a window restrictor in student accommodation was easily broken without tools, allowing a student to exit the window. It was suggested that risk assessments and more robust restrictors are appropriate in student accommodation to prevent falls.
Addressed to: Campus Living Villages; Department for Education
AI-generated concerns summaryThe coroner raised concerns that an urgent mental health act assessment application was rejected without the GP being notified, and urgent rejections were not clearly marked or accompanied by a phone call to the doctor.
Addressed to: Knowle House Surgery; Livewell South West, Mount Gould Hospital
AI-generated concerns summaryThe coroner noted a lack of equivalent safety regulations for non-commercial flights departing from unlicensed aerodromes compared to commercial flights from licensed premises, despite a previous accident identifying this regulatory gap.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryRegulations preventing take-off in poor visibility at licensed aerodromes do not apply to non-commercial flights from unlicensed aerodromes, a gap noted by the coroner despite previous accidents and recommendations.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner noted that regulations preventing take-off in challenging conditions from licensed commercial aerodromes do not apply to non-commercial flights from unlicensed aerodromes. This regulatory gap persists despite a similar accident in the 1990s and prior recommendations for establishing a special category for corporate aviation.
Addressed to: Civil Aviation Authority
AI-generated concerns summaryThe coroner noted delays in implementing an agreed care package and identified that there appeared to be no system for following up the implementation of such packages, raising concerns about potential impacts on vulnerable service users.
Addressed to: Norfolk County Council- Adult Social Care
AI-generated concerns summaryThe coroner identified concerns regarding a premature discharge from the Community Mental Health Service without adequate risk assessment or support, and the lack of a system to collate information from other agencies. The report also highlights the absence of a consistent multi-agency approach to high-risk individuals and suicide prevention across …
Addressed to: Southern Health NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the induction training for call handlers at Magenta Living Support Link, specifically on using a client's medical history and communicating changes in their presentation to emergency services. The report indicates a need to revisit the training manual and methods for call handlers.
Addressed to: Magenta Living Support Link
AI-generated concerns summaryThe coroner identified an incompatible IT system preventing urologists at Stepping Hill Hospital from viewing test results from Buxton. This led to a lacuna in follow-up care, as local GPs in Buxton either could not or did not act on crucial information, delaying diagnosis.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the suitability of a wooden shed as a firework store, particularly its licence for 1000 kg and the presence of other combustible materials. The licence was also deficient, failing to designate a specific site or type of explosive, and inspection records were incomplete.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Addressed to: Kent and Medway NHS and Social Care Partnership Trust
AI-generated concerns summaryThe report identifies a lack of regulation for private companies providing medical assistance at events, where medical knowledge was poor and CQC oversight was insufficient. It also highlights the unregulated status of 'ambulance technicians' and the absence of mentor suitability checks by private training providers.
Addressed to: Department of Health and Social Care; Lifeskills
AI-generated concerns summaryThe coroner noted that charcoal packaging instructions not to use indoors lacked prominence and did not explicitly warn of the risk of death from carbon monoxide poisoning.
Addressed to: Tesco Store PLC
AI-generated concerns summaryThe coroner highlighted an issue requiring national dissemination and requested confirmation that previous IPCC recommendations for police forces had been followed.
Addressed to: National Police Chiefs’ Council
AI-generated concerns summaryThe coroner raised concerns about the dangers of acetylfentanyl, a highly potent opioid sold as a 'legal high', noting that users may be unaware they have consumed an opioid with toxic effects like sedation and respiratory depression.
Addressed to: Department of Health and Social Care