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 Trust's protocol for patients unable to be contacted lacks clear stipulations for when police welfare checks are mandatory. A shift co-ordinator was also not conversant with the protocol, raising questions about its reinforcement within the team.
Addressed to: Kent and Medway NHS and Social Care Partnership Trust ("the Trust")
AI-generated concerns summaryThe coroner noted confusion over St Thomas' Hospital transfer protocols for aortic dissection patients and delays in accepting Mr Gilbert for transfer, which reduced his chances of receiving timely specialist surgery.
Addressed to: St Thomas' Hospital
AI-generated concerns summaryThe coroner noted that a lack of recording specific issues in patient notes and not using nursing notes for handovers risks significant information not being relayed to staff coming on duty.
Addressed to: BCUHB, Ysbyty Gwynedd
AI-generated concerns summaryThe coroner noted repeated issues identified by the PPO regarding the failure to assess risk of self-harm in new prisoners at Woodhill. A specific concern was that nursing staff did not participate in Mr Byrne's health screen or first review.
Addressed to: Ms Claire Murdoch, Chief Executive, Central and; Northwest London NHS Trust
AI-generated concerns summaryThe coroner identified concerns with emergency response procedures, including the immediate availability of first aid, delays in contacting emergency services, and difficulties paramedics faced in locating the casualty on site.
Addressed to: WE Rawson Ltd, Castle Bank Mills, Portobello Road, Wakefield
AI-generated concerns summaryThe coroner noted concerns regarding the absence of a clear protocol for agency and police involvement in student welfare checks, where student privacy appeared to take precedence over welfare, leading to delayed interventions.
Addressed to: Devon Partnership NHS Trust; Students Union, University of Exeter; University of Exeter
AI-generated concerns summaryThe coroner identified an absence of specific, prescribed training for staff on how to carry out and record observations of residents in the care home.
Addressed to: CARE UK
AI-generated concerns summaryDisjointed care was noted due to insufficient follow-up on a GP's medication recommendation and Phoenix Futures' inability to prescribe. An unexplained rescheduling of a mental health appointment also occurred despite the patient's self-harm risk.
Addressed to: Bodmin Road Health Centre; Greater Manchester NHS Area Team; Greater Manchester West Health NHS Trust
AI-generated concerns summaryThe coroner identified issues with Croydon University Hospital's urgent care streaming model, where a receptionist without medical training conducted initial assessments, delaying critical care. This raises questions about the appropriate qualification level for patient assessment and lessons for other Trusts.
Addressed to: Croydon Clinical Commissioning Group; Croydon Health Services; Virgin Care Wandle LLP
AI-generated concerns summaryThe coroner noted the absence of falls and bed rail risk assessments for Mrs Brown, an incomplete and unreviewed care plan, and a lack of clarity regarding assessment responsibilities. Concerns were also raised about insufficient night staffing levels, informal handovers, and inadequate auditing processes.
Addressed to: Your Health Ltd
AI-generated concerns summaryThe coroner noted the designated first aider was off-site and other non-native English-speaking workers lacked first-aid training and knowledge of the emergency number. Concerns were raised regarding employers ensuring all workers can summon emergency help.
Addressed to: Zelltec Limited
AI-generated concerns summaryInsufficient DSS input into CAMHS safety plans led to incomplete information for carers. A delayed multi-agency meeting missed support opportunities, and a DSS decision to close the case without senior review limited further assessments.
Addressed to: Denbighshire County Council
AI-generated concerns summaryThe coroner identified that quad bike riders are not required to wear crash helmets on public roads and that there are no additional driving qualifications needed to operate a quad bike.
Addressed to: Department for Transport; Driver and Vehicle Licensing Agency; Driver and Vehicle Standards Agency
AI-generated concerns summaryThe coroner raised concerns about communication difficulties between clinicians and hospital trusts, leading to delayed patient transfers and reviews. Issues also included a patient falling from bed due to inadequate supervision for an unstable neck fracture.
Addressed to: Royal Orthopaedic Hospital
AI-generated concerns summaryThe coroner noted that the suicide risk assessment section on the Mental Health Liaison Team's risk assessment document was frequently left incomplete, requiring risk to be inferred from actions rather than explicitly recorded.
Addressed to: Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted that the NICE Head Injury Pathway does not include Clopidogrel as a trigger for a CT scan after a head injury, unlike Warfarin, despite the increased risk of bleeding. This omission may affect timely diagnosis and treatment.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryCurrent protocols for when to seek renal advice for patients, particularly those who have undergone transplants, are limited, and there are questions regarding the availability of immunosuppressant medication at short notice.
Addressed to: Burton Hospitals NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the safety of the Millpond following three deaths, specifically the potential need for fencing, improved lighting, better warning notices, and accessible flotation equipment.
Addressed to: Pembrokeshire County Council
AI-generated concerns summaryThe coroner identified insufficient staff awareness and multi-disciplinary coordination regarding drug issues within the prison. Additional concerns included inadequate medication administration checks, limited cell searches, lack of overnight prisoner monitoring, and insufficient measures to prevent drugs entering the facility.
Addressed to: Birmingham Community Healthcare NHS Trust; Birmingham Prison; National Offender Management Service
AI-generated concerns summaryThe coroner noted that the attending paramedic lacked the confidence required to make a clinical decision.
Addressed to: Haughton Thornley Medical Centres; North West Ambulance Service