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 noted a lack of consistency and clarity among mental health staff regarding what constitutes an effective patient observation, specifically concerning whether to enter a patient's room, engage verbally, or check the environment, which contrasted with Trust policy.
Addressed to: Lancashire Care NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the appropriateness of the 60 mph speed limit on Cowleaze Hill, noting that the road's blind bends and cambers make it dangerous at that speed. There was also a lack of appropriate road signage.
Addressed to: Islands Roads
AI-generated concerns summaryPrison staff did not seek medical advice despite Mr. Black exhibiting signs of unwellness.
Addressed to: HMP Usk
AI-generated concerns summaryThe coroner raises concerns about insufficient information exchange during assessments for residential and nursing placements, noting a new care home was not provided with critical past incident details about a resident.
Addressed to: Kent County Council
AI-generated concerns summaryThe coroner noted the patient's DNAR status was fixed without family discussion, contrary to good practice. There was poor communication between nursing and medical staff, leading to a resuscitation attempt despite a DNAR order.
Addressed to: Care Quality Commission (CQC); Walsall Manor Hospital
AI-generated concerns summaryThe packaging of Fentanyl patches may not sufficiently warn patients about the serious consequences of using damaged patches.
Addressed to: Teva UK Ltd
AI-generated concerns summaryThe coroner identified a lack of pathways for post-ERCP patients with complications and issues with out-of-hours radiography referral, noting no surgical consultant was on call from Maidstone during the working week.
Addressed to: Maidstone and Tunbridge Wells NHS Trust
AI-generated concerns summaryThe coroner identified a lack of clear guidelines for patient assessment, obtaining medical history, and appropriate referral from the Intake team. Further concerns included insufficient patient monitoring and follow-up, and the failure to record or act upon crucial information provided by family members.
Addressed to: Policy and Patient Safety Directorate
AI-generated concerns summaryThe coroner noted that Mrs Scholey's wellbeing could have been safeguarded had relevant agencies been able to access and share information about her home environment. The report describes that the Multi-Agency Safeguarding Hub (MASH) in Wakefield, currently serving children, could be extended to include elderly and vulnerable adults.
Addressed to: Wakefield MDC; Wakefield District Safeguarding Adults Board
AI-generated concerns summaryThe coroner noted delays in mental health assessment, medication not administered, and an absence of a clear plan if the patient left the department. Insufficient communication with hospital security and police regarding the patient's mental state was also a concern.
Addressed to: Camden & Islington NHS Trust; Whittington Hospital NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the ambulance's delayed arrival, which only occurred after police intervention was needed to expedite the call.
Addressed to: Welsh Ambulance Trust
AI-generated concerns summaryInsufficient application and staff familiarity with the AWOL protocol were noted. The coroner also raised concerns about the absence of an inpatient Clinical Psychology service, creating a gap in direct referral options for hospital clinicians.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner identified that the effect of Heparin in causing confusion was not recorded or acted upon, and despite documented fall risks, there was no supervision arrangement in place, with nursing notes on risks not being reviewed or acted upon.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner noted people were unaware of dangerous currents below a waterfall, creating a risk of future deaths. A warning sign is needed to inform people of the waterfall pool's hazardous characteristics.
Addressed to: Gwynedd Council
AI-generated concerns summaryThe coroner noted the absence of warning signs for pedestrians and motorists at a dangerous crossing point on the A500 dual carriageway, where a stile leads to a gap in the central reservation at a national speed limit road.
Addressed to: Highways Agency
AI-generated concerns summaryThe report identifies a lack of a digital system for doctors and staff in the Emergency Department.
Addressed to: Betsi Cadwaladr University NHS Trust
AI-generated concerns summaryThe provided text is incomplete and does not contain specific concerns.
Addressed to: Brighton and Sussex University Hospitals NHS Trust; Care Quality Commission; NHS England; Clinical Commissioning Group; Goodlaw Solicitors; National Patient Safety Agency; Department of Health; Sussex Partnership Trust
AI-generated concerns summaryThe coroner raised concerns that body protection is not mandatory for motor cross competitors, believing it would have likely prevented the fatal injuries sustained in this case.
Addressed to: Motor Cross Federation
AI-generated concerns summaryThe coroner noted that the GP did not conduct a physical examination of the patient during a home visit, despite the patient complaining of pain following biliary reconstruction surgery.
Addressed to: Central Surgery
AI-generated concerns summaryThe coroner noted that a named nurse was not allocated until the day before the patient's death, contrary to trust policy. This resulted in essential duties like risk assessments, care plans, and family contact not being carried out.
Addressed to: South Essex Mental Health Partnership Trust; Lancashire Care NHS Trust