Browse 6,470 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 fatal iatrogenic injury went undetected for a prolonged period, poor record-keeping for best interest decisions and treatment, and inadequate governance processes at the Trust to identify and investigate incidents.
Addressed to: Chief Executive Officer, Barts Health NHS Foundation; Secretary of State for Dept. Health & Social Care
AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was found on the floor.
Addressed to: Worcestershire County Council
AI-generated concerns summaryThe coroner noted the absence of a specific practice tool in Wales for family and care staff to recognise and escalate signs of acute deterioration in people with learning disabilities. This lack contributes to avoidable deaths from conditions such as pneumonia, despite recommendations to adopt such tools.
Addressed to: Minister for Health and Social Care in Wales
AI-generated concerns summaryThe coroner identified a lack of clinical governance and integration for the Community Urology Service with NHS hospital services, along with insufficient appraisal and mandatory assessment for its clinicians. Concerns were also raised about the processes for granting independent practicing privileges.
Addressed to: Chief Executive, CQC; Integrated Care Board; Heath Secretary, Department of Health; Hospital Manager, Goring Hall; Managing Director, Sussex Medical Chambers
AI-generated concerns summaryThe coroner noted a lack of formal communication, information sharing, and handover systems for patients under the clinical care of the Intensive Support Service while admitted to the respite facility.
Addressed to: Leeds and Yorkshire Partnership Foundation Trust (Intensive Supportive Service); Leeds Survivor-Led Crisis Service (Leeds OASIS)
AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack of specific guidelines for managing suspected acute obstruction in patients taking Clozapine and identifying antipsychotic risks.
Addressed to: Croydon University Hospital; Medicines and Healthcare Products Regulatory Agency; Royal College of Emergency Medicine; Royal College of Psychiatrists; Secretary of State for Health & Social Care [REDACTED]; South London & Maudsley NHS Foundation Trust
AI-generated concerns summaryWest Midlands Ambulance Service paramedics did not adhere to national guidelines for breech birth management, with concerns noted regarding the absence of mandatory training for obstetric emergencies and insufficient uptake of new optional training due to resource limitations.
Addressed to: NHS Birmingham and Solihull ICB; NHS Black Country ICB; NHS Coventry and Warwickshire ICB; NHS Herefordshire and Worcestershire ICB; NHS Shropshire, Telford and Wrekin ICB; NHS Staffordshire and Stoke-on-Trent ICB; Association of Ambulance Chief Executive; West Midlands Ambulance Service
AI-generated concerns summaryThe coroner noted concerns that a low Wells score might be incorrectly interpreted as ruling out deep vein thrombosis or pulmonary embolus, as the score alone is insufficient to exclude these conditions.
Addressed to: President of the Royal College of General Practitioners
AI-generated concerns summaryThe coroner identified a gap in the law concerning powers of entry for emergency services, particularly paramedics, when responding to welfare concerns for potentially ill or incapacitated individuals. This lacuna, exacerbated by the 'Right Care, Right Person' model, can delay prompt and potentially life-saving treatment.
Addressed to: Ministry of Housing, Communities and Local Government; Secretary of State for the Home Department
AI-generated concerns summaryPatients risk being removed from inpatient bed lists prior to a mental health professional conducting an appropriate review on the same day, despite prior recommendations for admission or daily review.
Addressed to: Cheshire and Wirral Partnership NHS Trust
AI-generated concerns summaryThe coroner expressed concern about the police's narrow interpretation of policy, requiring explicit intent to end life before leaving A&E for a high-risk missing person. This, combined with ambulance services not responding to unknown whereabouts, risks delays in assistance.
Addressed to: Chief Constable of Cheshire Police
AI-generated concerns summaryThe coroner noted concerns regarding the hospital's aging building infrastructure and ongoing maintenance challenges, alongside critical care capacity issues and fears that patient safeguards could fail during high-pressure periods.
Addressed to: Cabinet Secretary for Health and Social Care; Chief Executive Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner noted that the NHS does not have the capacity to manage the significant volume of cancer referrals, which results in substantial delays for patients awaiting diagnosis, surveillance, and treatment.
Addressed to: NHS England
AI-generated concerns summaryPoor record keeping was identified in key areas such as falls, wound management, and discharge handovers. There was also a lack of understanding or adherence to aseptic techniques and cleanliness during wound management, increasing infection risk.
Addressed to: Mr Nick Mallaband, Acting Chief Medical Director, Doncaster & Bassetlaw NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that mechanical thrombectomy services are unavailable outside of 9 am to 5 pm in the region due to insufficient neuroradiologists, potentially leading to preventable deaths.
Addressed to: NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
AI-generated concerns summaryThe coroner noted that restaurants and food establishments may be unaware of devices available to assist in choking incidents and questioned who is responsible for advising them of such items.
Addressed to: East Riding Council; Health and Safety Executive; Food Standards Agency
AI-generated concerns summaryThe coroner noted a lack of training for prison officers regarding decision-making in dynamic situations with competing priority tasks, such as multiple emergency cell bells and ACCT checks. Senior staff briefings also failed to provide guidance on managing these competing priorities.
Addressed to: Governing Governor, HMP Leeds
AI-generated concerns summaryThe Trust's patient information leaflets on 'Birth after caesarean' lacked a full explanation of uterine rupture, impacting informed consent for VBAC. There are concerns that the Trust may not be implementing changes following serious clinical incidents within a reasonable timeframe.
Addressed to: Chief Executive, Great Western Hospitals, NHS Trust Marlborough Road, Swindon, SN3 6BB
AI-generated concerns summaryThe RCOG information leaflet on birth options after a previous caesarean section does not state that uterine rupture can be fatal for mother or baby, raising concerns that parents may make uninformed choices about VBAC.
Addressed to: President, Royal College Obstetricians and Gynaecologists (RCOG) 10-18 Union Street, London SE1 1SZ
AI-generated concerns summaryThe coroner noted that flood risk reduction options for Tapton Terrace, identified following 2007 flood damage, were not implemented due to cost, leaving the area vulnerable and posing a risk to residents' lives.
Addressed to: Environment Agency; Derbyshire County Council; [REDACTED], Parliamentary Under-Secretary of State (Minister for Water and Flooding)