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 identified the absence of a venothromboembolism risk assessment model in the Emergency Department for patients discharged with lower limb immobilisation, noting a 'postcode lottery' in prophylaxis across different Trusts and inconsistency with NICE guidance.
Addressed to: LTHTR; LTHTR
AI-generated concerns summaryThe coroner noted that a call regarding an unconscious man did not receive red prioritisation, raising concerns about a potential pattern in the London Ambulance Service's handling of calls for unconscious patients.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner's specific concerns are detailed within an enclosed report authored by Dr Stephen Hoole, which was referenced in the PFD.
Addressed to: Plymouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the care on ward 225, where the deceased, who had Down Syndrome, was given inappropriate solid foods and drinks with unsuitable cups despite a risk of aspiration. Nursing staff frequently disregarded specific care requirements for his oral intake.
Addressed to: University Hospital of North Staffordshire
AI-generated concerns summaryA fresh risk assessment was not evidently prompted following a noted deterioration in the deceased's condition. Additionally, the report describes inadequate fire risk management at Greenrod Place.
Addressed to: Adult Social Services; Greenrod Place
AI-generated concerns summaryThe distance between the touchline and the clubhouse was less than FA recommended guidelines, potentially putting players at risk, and the referee did not take action regarding this on the day.
Addressed to: The FA Group
AI-generated concerns summaryFailings in nursing care were identified for a patient with learning disabilities, alongside inadequate communication with their carers and family. The report also raised concerns about assumptions made regarding the health of individuals with learning disabilities.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe report identifies recurring issues related to the Acute Medical Unit (AMU), specifically regarding the care provided to patients admitted with acute illness.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted inconsistent understanding among officers regarding armed containment, a lack of guidance from trained hostage negotiators for untrained officers, and post-incident management procedures that eroded public confidence and hampered learning.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryCare plans for patients discharged into the care of family members following mental health assessments are agreed orally and not documented for the family, leading to uncertainty about responsibilities.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns about the lack of fire hazard warnings on paraffin-based emollient creams like Cetraben and insufficient communication of fire risks to patients. Existing guidance may not adequately cover proprietary creams with lower paraffin content.
Addressed to: National Patient Safety Agency; Chief Fire Officers Association; Staffordshire Fire and Rescue Service
AI-generated concerns summaryThe coroner noted the absence of a protocol for assessing patients in the Plaster Room, which led to a patient with deep vein thrombosis symptoms being discharged without medical review.
Addressed to: Coreys Mill Lane; East & North Hertfordshire NHS Trust; Herts. SG1 4AB; Mr N Carver; Stevenage
AI-generated concerns summaryThe report identifies a lack of formal communication for family concerns and insufficient guidance for prison staff on supporting potential abuse victims. Non-healthcare staff also inappropriately relied on a subject's presentation without further investigation.
Addressed to: HMP HUMBER (EVERTHORPE SITE)
AI-generated concerns summaryConcerns were raised regarding the shortage of acute psychiatric beds in Cornwall and inadequate staffing at designated mental health places of safety. This leads to patients being inappropriately detained in police cells or transported out of county.
Addressed to: Department of Health and Social Care, Curnow Commissioning Group and NHS England
AI-generated concerns summaryThe coroner noted poor medical and nursing note-keeping at Alexandra Hospital, including a lack of full medical history pre-operatively and discharge despite low oxygen levels. There were also unanswered out-of-hours calls to the District Nursing team.
Addressed to: BMI Healthcare; GTD Healthcare
AI-generated concerns summaryThe coroner noted concerns regarding the deceased's unsuitable accommodation, evidence of self-neglect including soiled bedding, and that the care package in place appeared inappropriate.
Addressed to: Plymouth City Council
AI-generated concerns summaryThe coroner noted the absence of a Medication Reconciliation policy at University Hospital of Wales, which made it difficult to identify medication omissions. Concerns were raised that other Health Boards in Wales might also lack this policy, potentially risking future deaths.
Addressed to: Aneurin Bevan University Health Board; Betsi Cadwaladr University Health Board; Cardiff and Vale University Health Board; Cwm Taf Morgannwg University Health Board; Hywel Dda University Health Board; NHS Wales; Powys Teaching Health Board; Swansea Bay University Health Board; Welsh Assembly Government
AI-generated concerns summaryThe coroner noted concerns that NHS Pathways for toddlers and children may not effectively identify very sick children, and that no changes have been made to address this ongoing risk.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified inadequate monitoring of a change in medication, a lack of review or alternative care coordinator during an extended absence, and staffing shortages within the Trust.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the continued practice of locking detainees in rooms overnight, contrary to previous recommendations. The report also identified deficiencies in staff detention awareness training, communication of detainee circumstances, and protected time for personal officers.
Addressed to: Home Office; Ministry of Justice