Browse 6,493 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 limited CCTV coverage and access, suggesting that a more extensive installation and monitoring could help identify risks of individuals harming themselves or damaging property, enabling earlier intervention.
Addressed to: Darlington Cattle Mart
AI-generated concerns summaryConcerns identified include registrars' clinical judgment errors, such as delayed medication and an incorrect decision on passive descent, and inadequate record-keeping. The hospital's incident investigation process also lacked robust systems for staff involvement and feedback, hindering learning.
Addressed to: Whittington Hospital NHS Trust
AI-generated concerns summaryCommunity healthcare providers did not use a sepsis screening tool, missing opportunities for diagnosis and emergency referral. An NHS England patient safety alert regarding a UK sepsis clinical toolkit had not been recognised or adopted.
Addressed to: West Leicester CCG; East Midlands Ambulance Service; NHS England; Loughborough, Leicestershire
AI-generated concerns summaryInstructions from Queen Elizabeth Hospital for an MRI scan were not followed by Good Hope Hospital staff, highlighting a need for systems to ensure specialist advice is adhered to.
Addressed to: Heart of England NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner identified inadequate and fragmented record-keeping at the care home, impacting staff's ability to track care and confirm facts. Concerns included insufficient staff training for medical situations, delays in podiatry care, and the absence of a post-incident review.
Addressed to: Shawe Lodge
AI-generated concerns summaryPost-operative instructions were not followed by nursing staff, and rising EWS observations were not reported to medical staff. The Interventional Radiology team lacked understanding of nursing observations, highlighting a need for improved inter-team communication.
Addressed to: University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner noted that brittle asthma is not covered by the medical exemption certificate, unlike other conditions requiring continuous medication. This created a financial barrier to obtaining prescriptions, which meant the GP did not escalate the patient's case or reassess asthma control.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the free availability and misuse of dangerous "research chemicals" like MXP, which are sold over the internet yet are not controlled substances. A review of MXP's status and control was requested to prevent future deaths.
Addressed to: Advisory Council on the Misuse of Drugs; Home Office; Minister of State for Crime Prevention
AI-generated concerns summaryThe coroner raised concerns about ambulance service policies on obtaining and saving patient medical history, call-back procedures for unresponsive patients, and staff abstraction levels. Further issues were noted regarding time loss during ambulance handovers to hospital A&E.
Addressed to: East Midlands Ambulance Service; Freeth Cartwright Solicitors; Kettering General Hospital NHS Trust
AI-generated concerns summaryThe coroner identified an unexplained significant departure from a patient's management plan during a period of rapid deterioration. Concerns were also raised regarding unactioned crucial blood analysis results and inadequate completion of nursing and medical notes.
Addressed to: North Tyneside General Hospital
AI-generated concerns summaryThe coroner identified a lack of systems at The Priory Hospital, Altrincham, for contacting patients who repeatedly miss appointments, informing GPs about non-attendance or discharge, and ensuring appropriate review before medication changes are made.
Addressed to: Priory Hospital
AI-generated concerns summaryThe coroner identified that the Section 136 assessment for Rebecca Jones was not conducted within the expected three-hour timeframe. This delay occurred because urgent assessments were required for other vulnerable persons, indicating a potential capacity issue at the facility.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified inadequate stock control and security for non-controlled drugs in patient drawers and ward cupboards at Royal Bolton Hospital, posing a risk of unrecorded removal or excess dosage. This was compounded by insufficient pharmacist checks.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryConcerns were raised regarding the lack of follow-up action after a nurse identified signs of stress in a child and arranged for a doctor to see him. The matter was not pursued further when letters sent to the child's mother received no reply.
Addressed to: Norwich Practices Health Centre
AI-generated concerns summaryClinicians experienced difficulty accessing comprehensive patient information because relevant data was stored in disparate record 'silos'. The coroner noted a concern that the current approach to NHS record sharing does not adequately address these risks.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns included a recurring problem with investigative test results not being available with patient notes or electronically uploaded, and the absence of a protocol or labels for intravenous lines, which contributed to an accidental disconnection.
Addressed to: Cardiff and Vale University Health Board
AI-generated concerns summaryThe coroner raises concerns that standard tracheostomy tube lengths may be inappropriate for the increasing size of the population, potentially contributing to complications like dislodgement. The Intensive Care Society is encouraged to influence the industry to address this issue.
Addressed to: Intensive Care Society of England and Wales
AI-generated concerns summaryThe care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.
Addressed to: Nant y Gaer Hall Nursing Home
AI-generated concerns summaryThe coroner noted that the absence of a pre-operative orthogeriatric review for patients with a fractured neck of femur may lead to the use of cemented hemiarthroplasty, which carries a risk of mortality from bone cement implantation syndrome.
Addressed to: Kings College Hospital
AI-generated concerns summaryConcerns were raised regarding the lack of liaison and generic risk assessment prior to a white water rafting trip, alongside an inadequate dynamic risk assessment of river conditions and an absence of preparatory training, water confidence tests, and a safety kayak. There was also no obligation to liaise with the …
Addressed to: Sports Camp Tirol