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 summaryDischarge letters noting a dangerous side effect were not sent to the patient's GP, and the hospital's internal records were not updated with vital drug sensitivity information.
Addressed to: Royal Devon and Exeter Hospital
AI-generated concerns summaryThe coroner identified insufficient handover procedures regarding a patient's need for ambulatory oxygen during transfer between hospital departments. This led to ward staff being unaware of the patient's oxygen requirements, and portable oxygen not being used when he went to the toilet.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryThe coroner raises concerns about a general unawareness of rip current risks for individuals entering the sea and notes a lack of specific rip current risk assessment. There is also a need for clear guidance on how to escape rip currents if caught.
Addressed to: Lattitude Global Volunteering
AI-generated concerns summaryThe coroner identified significant blind spots in light goods vehicles under 3.5 tonnes. A lack of legislation requiring reversing aids means these vehicles operate without safety features that could prevent collisions with pedestrians.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted a discrepancy between medication records following hospital discharge and a lack of a protocol to easily check such discrepancies, particularly on weekends.
Addressed to: Good Hope Hospital
AI-generated concerns summaryThe provided text is incomplete and does not contain any discernible coroner's concerns.
Addressed to: Brighton and Sussex University Hospital NHS Trust; Princess Royal Hospital
AI-generated concerns summaryThe coroner raised concerns about the patient being left without a Care Co-ordinator and not being informed of discussions about her medication review request. Additionally, the Mental Health Team's response to urgent concerns from a Health Visitor was noted as delayed.
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the safety of Maplin N19KJ telescopic ladders, noting approximately 43,000 units were sold before withdrawal due to safety issues. Further investigation is sought regarding the accident ladder's origin and a review by Maplin.
Addressed to: Derbyshire Trading Standards Division
AI-generated concerns summaryThe coroner raised concerns regarding the need for full and adequate training for all police officers on how to fully interrogate details relating to markers held on the Police National Computer (PNC).
Addressed to: Surrey Police
AI-generated concerns summaryThe coroner noted the emergency link officer lacked formal medical training for assessing head injuries, and there were no clear policies on managing these cases or determining when to summon an ambulance. Concerns were also raised about service adequacy given the geographical distance.
Addressed to: Peaks and Plains Housing Trust
AI-generated concerns summaryThe coroner noted overgrown hedgerows obscuring views at a junction, a lack of signage to indicate its presence, and the absence of a curtailed speed limit despite the junction's location.
Addressed to: Leicestershire County Council
AI-generated concerns summaryThe coroner identified concerns regarding the process for gathering information for mental health assessments, assessing their urgency, and sharing this information with other agencies. Further concerns relate to establishing responsibility for patient care and ensuring clear communication during transfers between agencies.
Addressed to: Avon and Wiltshire NHS Mental Health Partnership Trust; Royal United Hospitals Bath NHS Foundation Trust; Wiltshire Council
AI-generated concerns summaryThe family perceived a lack of staff over a Bank Holiday weekend, leading to delayed interventions, poor nutritional support, and inadequate pain control. Concerns were also raised about poor communication from nursing staff.
Addressed to: am Margaret; Jones, Assistant Coroner, for Stoke-on-Trent & North Staffordshire.
AI-generated concerns summaryThe coroner noted that official drug information (SPC/PIL) lacks guidance for prescribers to inquire about a history of substance misuse and for patients to be cautious about potential adverse interactions between prescribed medicines and drugs of misuse. This gap applies to interactions beyond just SSRIs and cocaine.
Addressed to: Medicines and Healthcare products Regulatory Agency
AI-generated concerns summaryThe report identifies a need for prompt and clear information sharing between healthcare providers for vulnerable adults whose primary care is outside their local Clinical Commissioning Group area. It also suggests sharing such information with police.
Addressed to: Devon County Council; Northern Eastern and Western Devon Clinical Commissioning Group; Plymouth City Council; Torbay and South Devon Clinical Commissioning Group; Torbay Council
AI-generated concerns summaryThe coroner noted that Mr. Bahar, a patient with Stage 4 Chronic Kidney Disease, was inappropriately prescribed and given Codeine, which was a breach of both hospital policy and national guidance and led to severe opiate toxicity.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the absence of trust guidelines for chest drain insertion, a lack of up-to-date staff training on the procedure, and an unawareness of interventional radiologist availability during weekends.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified inadequate observation, general welfare care, and a lack of clear window opening policies at Berrycroft. Concerns were also raised regarding the Council's safeguarding investigation process, described as vague, unstructured, and over-reliant on care home staff statements.
Addressed to: Berrycroft Manor Care Home; Stockport Metropolitan Borough Council
AI-generated concerns summaryThe coroner identified a lack of medication reviews in accordance with accepted practice and no system to ensure them. There was also insufficient cohesion between mental health and medical treatment, which meant staff lacked access to mental health information for vulnerable patients.
Addressed to: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW
AI-generated concerns summaryThe coroner noted multiple rear-end collisions on Sheppey Road Bridge. A 2015 safety review concluded that bridge geometry and high speeds impacted safety, recommending a 50 mph speed limit, but this recommendation has not been implemented.
Addressed to: National Highways