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 GP referral form for the rapid access endoscopy scheme is limited, which may lead to the omission of important past medical history needed by the endoscopist.
Addressed to: Kent and Medway Cancer Collaborative
AI-generated concerns summaryInsufficient staff cover for 1:1 patient care on Holdsworth ward, and likely other wards, leads to preventable falls and care deficiencies that may contribute to death.
Addressed to: St George’s Hospital
AI-generated concerns summaryThe coroner raised concerns about the withdrawal of urgent endoscopy services at Trafford General Hospital, questioning the safety of treating acutely unwell patients requiring such essential procedures at the facility. This led to patient transfers and delays in accessing critical care.
Addressed to: Central Manchester NHS Trust
AI-generated concerns summaryConcerns were raised about the use of two separate sets of patient notes causing confusion, and that the deceased was repeatedly denied hospital appointments and discharged prematurely, potentially delaying diagnosis and impacting care.
Addressed to: Tameside Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a patient was discharged as medically fit by a doctor who had not seen them, relying on nurse information and colleagues' assessments. Concerns were also raised about the erroneous omission of the patient's long-acting insulin during their hospital stay, which altered their medication regime.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the consideration given to ACCT care plans when a Cell Sharing Risk Assessment (CSRA) indicates a prisoner should be in a single cell for the protection of others, questioning if existing policy adequately covers this.
Addressed to: 102 Petty France; SW1H 9AJ; The Secretary of State for Justice
AI-generated concerns summaryThe coroner raised concerns about the clarity of Matrifen leaflet warnings regarding hot baths and Macmillan Nurses' advice on patch removal. There were also identified gaps in liaison between Macmillan Nurses and the GP practice, alongside unclear GP patient notes.
Addressed to: Churchgate Surgery; Macmillan Cancer Support; Takeda UK Ltd
AI-generated concerns summaryThe coroner raises concerns that large goods vehicles registered before January 26, 2008, are not legally required to have Class VI front mirrors, meaning drivers cannot see pedestrians or cyclists positioned directly in front, which could lead to future collisions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of reliable air support in North West Wales during night hours and an ineffective rota, communication, and recruitment process for Community First Responders. Concerns were also raised about the Welsh Ambulance Service Trust not increasing resources for seasonal population increases.
Addressed to: EMERGENCY AMBULANCE SERVICE COMMIT-TEE FOR WALES; Welsh Ambulance NHS Trust; Welsh Assembly Government
AI-generated concerns summaryThe coroner noted support workers lacked keys to premises, potentially leaving residents unobserved when admitting other staff, and raised concerns regarding the adequacy of staff numbers, risk management procedures, and staff training related to care plans.
Addressed to: United Response
AI-generated concerns summaryConcerns included that 5F AKB-48 and SF PB-22 are not controlled under the Misuse of Drugs Act 1971, and that the deceased had not reported his chronic misuse of cannabinoid receptor agonists to the DVLA.
Addressed to: Driver and Vehicle Licensing Agency; Home Office
AI-generated concerns summaryCare providers in the community lack adequate training to interpret special health monitoring devices (Telehealth) and act on the information provided. This leads to missed conditions, and the coroner highlights the need for county-wide implementation of relevant training recommendations.
Addressed to: Cornwall and Isles of Scilly Safeguarding Adults Board
AI-generated concerns summaryNursing staff did not identify a missed steroid dose, and there is no system, either paper or electronic, to alert medical staff about patients on long-term steroid treatment.
Addressed to: Great Western Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner expressed concern that individuals with complex needs and variable mental capacity faced significant difficulty navigating multiple agencies and understanding service funding. This "agency blindness" prevented access to support, compounded by changes in funding models and complex paperwork requirements.
Addressed to: Cornwall Council Local Adult Safeguarding Board
AI-generated concerns summaryThe coroner identifies that the increased speed and power of leisure power boats create additional risks, requiring users to be more aware to prevent accidents.
Addressed to: British Maritime Federation; Royal Yachting Association
AI-generated concerns summaryThe coroner noted an increase in the speed and power of leisure power boats, which creates additional risks that users should be made aware of to prevent accidents.
Addressed to: British Maritime Federation; Royal Yachting Association
AI-generated concerns summaryThe coroner raised concerns that some care homes in Cornwall may lack adequate policies for recognising and confirming death, and for resuscitation. There are also concerns that existing policies might not be regularly updated, or that staff may not be aware of them or adequately trained.
Addressed to: Care Quality Commission; Cornwall and Isles of Scilly Safeguarding Adults Board
AI-generated concerns summaryThe coroner notes inconsistencies between West Mercia Police's policy and national guidance on wrong-way dual carriageway pursuits, impacting officer training. A lack of explicit communication protocols between pursuing officers and supervisors during high-risk tactics was also identified.
Addressed to: West Mercia Police
AI-generated concerns summaryInsufficient clarity and communication regarding early patient discharge assessment requirements were noted, along with unclear documentation. Additionally, there was no process for family members, who would provide care, to input their views or understand the discharge decision.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryThe coroner identified a need to review and consider implementing deterrent measures on the walls of the viaduct where the deceased jumped.
Addressed to: SUSTRANS