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 summaryCritical information regarding threats of self-harm was not effectively communicated from the incident log to arresting officers, custody staff, or the custody sergeant, impacting their risk assessment.
Addressed to: Lincolnshire Police
AI-generated concerns summaryThe coroner noted inadequate and incomplete medical and nursing record keeping, specifically regarding seizure charts. The report also highlights a need for more robust recording of events when patients develop seizures.
Addressed to: Hospital NHS Trust Derriford Hospital; Borchardt Medical Centre
AI-generated concerns summaryThe coroner identifies a lack of policy for reporting tall buildings encroaching on Heliport flight paths and insufficient consultation between planning and airport authorities on air safety. An unimplemented AAIB recommendation for assessing new obstacles before planning permission is also noted.
Addressed to: Civil Aviation Authority; Department for Transport; London Heliport
AI-generated concerns summaryThe coroner identified a lack of specific policy and in-depth consultation regarding tall buildings impacting London Heliport flight paths. Further concerns included the non-implementation of a 2014 safety recommendation for the CAA to assess new obstacles before planning permission.
Addressed to: Civil Aviation Authority; Department for Transport; London Heliport
AI-generated concerns summaryThe coroner noted the GP's domestic violence flowchart was vague and focused on depression rather than abuse risk, lacking a specific questionnaire for domestic abuse. There was also no method for staff to escalate urgent patient calls.
Addressed to: Old Catton Medical Practice
AI-generated concerns summaryThe coroner raised concerns about the inadequate documentation and escalation of family-reported abdominal pain to the medical team, resulting in a lack of examination. Additionally, insufficient record-keeping by medical professionals, including out-of-hours GPs, was noted.
Addressed to: Royal Bolton Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner identified concerns regarding the rigid legal handover of placement duties at age 18, which may occur before a young person's Transition Plan is completed. Also noted were gaps in knowledge and interagency working between social care and the secure estate for transition planning.
Addressed to: General Medical Council; London Borough of Tower Hamlets; National Offender Management Service
AI-generated concerns summaryThe coroner noted gaps in staff observation protocols, insufficient procedures for mental health patient transfers involving police, and a lack of environmental risk assessment for an outdoor area. There was also no formal agreement between services for managing detained patients in A&E.
Addressed to: James Paget University Hospital; Norfolk and Norwich University Hospital; Norfolk and Suffolk NHS Foundation Trust; Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner identified concerns regarding the Trust's processes for handling and recording third-party information, particularly regarding confidentiality. There was also minimal multi-disciplinary team involvement in patient care and the serious incident review process did not pick up all concerns.
Addressed to: South Staffordshire and Shropshire NHS Trust; St George’s Hospital
AI-generated concerns summaryThe coroner identified delays in diagnosing a caecum perforation, citing issues with the timely prompting and performance of CT scans, and obstetric registrars not seeking surgical consultation. Concerns also included the inappropriate use of the modified obstetric early warning score tool for sepsis identification.
Addressed to: Royal London Hospital
AI-generated concerns summaryThe coroner identified that pulse oximeter alarm settings are routinely fixed at 85% and do not account for individual patient's normal base oxygen levels. This raises a potential risk to patients if a significant drop from their baseline does not trigger an alarm.
Addressed to: BCUHB, Ysbyty Gwynedd
AI-generated concerns summaryThe system for radiologist reports delivered to the Emergency Department lacks reliability and a coding system to prioritise reports identifying injuries, and the paper report delivery method is flawed, sometimes leading to reports not arriving.
Addressed to: BCUHB, Ysbyty Gwynedd
AI-generated concerns summaryThe coroner identified a lack of communication between the GP and podiatrist, insufficient clarity on GP responsibility for secondary care referrals, and an administrative failure that prevented a referral letter from being dispatched.
Addressed to: G4S Medical Services; Premier Physical Healthcare; Spectrum Community Health CIC
AI-generated concerns summaryThe practice lacked systems to ensure patients on citalopram received appropriate medical reviews every 3-6 months, as one patient went over 3 years without review, potentially missing signs of deterioration.
Addressed to: Jockey Road Medical Centre
AI-generated concerns summaryThe coroner identified serious deficiencies in the driver medical assessment process, including insufficient investigation of health conditions on form POLN3 and inadequate follow-up on GP referrals. These gaps risk drivers operating vehicles without being properly assessed for fitness.
Addressed to: The Driver and Vehicle Licensing Authority
AI-generated concerns summaryConcerns were raised regarding the frequent administration of Omnipaque at doses exceeding manufacturer's guidelines, particularly through central lines, which may expose interventional radiology patients to toxicity risks.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of joint guidance for anaesthetists and ENT surgeons on the preferred mode of front-of-neck access in "Can't Intubate Can't Oxygenate" situations, leading to limited experience among practitioners.
Addressed to: ENT UK; Royal College Anaesthetists
AI-generated concerns summaryThe coroner identified a two-hour delay in doctor attendance following a request, insufficient nursing monitoring and observations, and a general poor standard of record-keeping by both nursing and medical staff.
Addressed to: Calderdale and Huddersfield NHS Foundation Trust
AI-generated concerns summaryThe gym did not enforce the use of the emergency stop cord, despite advising users to attach it, which raised concerns about the adequacy of advice and warnings provided to users.
Addressed to: Birmingham City Council
AI-generated concerns summaryThe coroner noted that procedures for identifying suicidal intent failed under demanding conditions due to insufficient support for inexperienced staff. There was also a lack of clarity and communication between GEOAmey and prison reception staff regarding the handover of critical SASH forms.
Addressed to: CARE UK; G4S; GEOAmey; HMP Durham; National Offender Management Service