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 summaryConcerns were raised about a significant delay in Mrs. Darbyshire receiving an urgent CTPA procedure, attributed to the clinical team not chasing it up and the radiology department's incorrect patient categorisation. These issues were potentially exacerbated by reduced staffing during the Christmas period.
Addressed to: Blackpool Teaching Hospital NHS Foundation Trust
AI-generated concerns summaryThe Pathways system fails to prompt CPR advice for agonal breathing, a known fault Pathways has not amended. There were also delays in ambulance dispatch and arrival, partly due to paramedic shortages and hospital handover delays.
Addressed to: Care Quality Commission; Department of Health and Social Care; North East Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe quality of mental health risk assessments was noted as diminished due to staff unawareness of policies and the routine use of untrained interpreters without guidance. The coroner also identified that a Serious Incident Review was not undertaken, delaying learning opportunities.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust; Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted the high flammability of man-made fabric clothing worn by the deceased and enquired about potential measures to reduce the flammability of manufactured or imported garments in the UK.
Addressed to: Department of Business Innovation and Skills
AI-generated concerns summaryThe coroner identified a lack of proper implementation and follow-up on a vulnerable patient's care plan, which meant the Out of Hours service did not have access to critical medical history, including the reason for asthma pump use without a diagnosis.
Addressed to: City and Hackney GP Confederation; Lawson Practice
AI-generated concerns summaryThe internal investigation report was insufficiently robust, failing to interview key witnesses or consider the clinical content of documentation, and contained factual inaccuracies. The Trust also lacked a system for urgent recall of patients discharged with potentially life-threatening conditions.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the communication of 'special instructions' during a surgical procedure to other medical personnel, specifically via the WHO/Surgical checklist.
Addressed to: Not Listed
AI-generated concerns summaryThe coroner raises concerns about the ease with which illicit and unregulated drugs are obtained via the "Dark Web," noting the anonymity of suppliers, unknown drug content, and the lack of regulation for internet drug supply and postal delivery.
Addressed to: Home Office
AI-generated concerns summaryA delay of up to 24 hours in writing medical consultation records risks important information not being available or being misinterpreted by other healthcare professionals, potentially harming patients. The coroner recommends compliance with GMC guidelines for timely record-keeping.
Addressed to: Priory Group
AI-generated concerns summaryCatheterisation was performed by multiple individuals without a consolidated record, leading to staff being unaware of previous challenges and delaying timely involvement of a Urologist.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the window was not fitted with a safety device. Concerns were raised regarding the need to review its safety and take remedial action for similar windows across properties to comply with building regulations.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe London Ambulance Service had insufficient resources available to meet demand on 7th February 2013.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the patient developed diabetes while on Clozapine, and routine blood tests for blood sugar would likely have prevented the diabetic coma and subsequent trachea injury that led to death.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that a disused railway bridge (ABO8) is easily accessible to the public, including children, with no measures in place to prevent access despite its location next to a main road and frequent visits.
Addressed to: Highways England; Historical Railways Estate
AI-generated concerns summaryThe coroner identified inadequate height of fixed barriers and fall protection at the gantry's access ladder, noting the absence of an intermediate crossbar and a toe-plate. Recommendations included safer barrier heights, self-closing mechanisms, and a falls arrest system.
Addressed to: Steadplan Ltd; Freight Transport Association Ltd; Road Haulage Association
AI-generated concerns summaryThe coroner identified a complete misunderstanding by Greater Manchester Police (GMP) of the Notifiable Occupation Scheme, leading to an 18-month failure to make post-conviction notifications and no recording system for pre-conviction disclosures. Concerns were also raised about the incompleteness and lack of clarity in the proposed replacement scheme.
Addressed to: Greater Manchester Police; Home Office; Ministry of Defence; Ministry of Justice; National Offender Management Service; National Police Chiefs’ Council; Pennine Care NHS Foundation Trust; Security Industry Authority
AI-generated concerns summaryThe coroner identified that assessing a patient's fitness to travel and transport method requires medical expertise beyond a paramedic's. Concerns were raised about reliance on family and distant hospitals, and the need for independent medical assessment in direct repatriations without insurance facilities.
Addressed to: Exora Medical Limited
AI-generated concerns summaryThe coroner notes that important patient information from the CANDI service is not readily accessible to other Trust services without a proactive request, and access methods for out-of-hours situations are unclear.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that doctors did not routinely telephone patients or their families when a home visit was requested to obtain further information, which could have led to a priority visit in this case. A system for pre-visit telephone contact has since been introduced and should be drawn to the …
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified an error where Mrs Corah underwent an X-ray intended for another patient, leading to treatment delay and unnecessary radiation exposure for her, and also adversely affecting the patient for whom the X-ray was originally requested.
Addressed to: Nottingham University Hospitals NHS Trust