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 NHS Mental Health Team did not seek historical information or input from the patient's previous private clinicians, which could have assisted in her treatment.
Addressed to: Berkshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the high potency and toxicity of Acetylfentanyl, an unlicensed opioid analgesic drug available legally over the internet, and expressed concern that its free availability could lead to further deaths.
Addressed to: Advisory Council for the Misuse of Drugs
AI-generated concerns summaryThe coroner raised concerns regarding the ambulance service's policy and training on the Mental Capacity Act, specifically concerning protocols for using restraint or force when a patient refuses transport to hospital.
Addressed to: South Western Ambulance Service
AI-generated concerns summaryConcerns were raised regarding inadequate patient transfer and incomplete handover from the Acute Medical Unit. There were multiple deficiencies in basic care, including hygiene and pressure area management, incomplete essential monitoring charts, and a failure to escalate elevated NEWS scores to doctors.
Addressed to: Brighton and Sussex University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the NHS does not routinely offer antenatal screening for Group B Streptococcus (GBS) or prophylactic intrapartum antibiotics to all GBS-positive pregnant women, raising concerns about potential risks to babies.
Addressed to: Department of Health and Social Care; National Institute for Health and Care Excellence; Royal College of Obstetricians; Royal College of Paediatricians
AI-generated concerns summaryThe coroner noted insufficient training for PIC staff in interpreting National Early Warning Scores and understanding clinical signs, impacting patient assessment. There is also no clear service level agreement or guidance for information sharing between PIC and local GPs.
Addressed to: Annesley Woodhouse; Partnerships In Care
AI-generated concerns summaryThe coroner raised concerns regarding the absence of street lighting at the junction and suggested staggering the junction to prevent vehicles from driving straight through across Fosseway.
Addressed to: Warwickshire County Council
AI-generated concerns summaryAbnormal patient observations were not recognised as requiring further action, with the coroner suggesting a system similar to an Early Warning Score. Concerns were also raised about the attending nurse not accessing available healthcare records, leading to observations being taken without full clinical context.
Addressed to: Leicester Partnership Trust
AI-generated concerns summaryThe coroner identified unclear protocols for mental health patients brought voluntarily by police, resulting in inadequate information sharing between agencies and incomplete risk assessments. Concerns were also noted regarding poor record-keeping and insufficient urgency in escalating patient information.
Addressed to: Camden and Islington NHS Foundation Trust; Metropolitan Police Service; Whittington Hospital NHS Trust
AI-generated concerns summaryThe coroner noted a lack of systems at Springfield Medical Centre to identify uncollected prescriptions, particularly for vulnerable patients needing anti-epileptic medication. This meant General Practitioners were not alerted when the patient did not collect vital medication, despite prior consultant concerns about adherence.
Addressed to: Springfield Medical Practice
AI-generated concerns summaryThe coroner noted concerns regarding Newgate Street surgery's INR monitoring system, specifically the reliance on healthcare assistants for clinical information when making dosing decisions. There was also a lack of an internal investigation to ensure all GPs learned from the events.
Addressed to: Risk and Patient Safety, Nottinghamshire Healthcare NHS Foundat; Newgate Medical Group
AI-generated concerns summaryRasharn's care plan lacked clarity regarding when to call an ambulance for breathlessness, potentially creating ambiguity for staff. A medical notice with his photograph and instructions was also not displayed at the time of his death.
Addressed to: Berger Primary School
AI-generated concerns summaryA defective surgical anastomosis following a right hemicolectomy was not detected prior to hospital discharge, which the coroner identified as a factor that, if detected earlier, might have prevented the death.
Addressed to: Glan Clwyd Hospital
AI-generated concerns summaryThe coroner identified numerous front suspension failures in UK-modified Ridgeback vehicles due to increased weight and requested a review of the entire suspension system. Concerns were also raised regarding height restrictions for vehicle drivers and commanders.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner raises concerns about the lack of a system to ensure requested blood tests are reported to GPs, and insufficient processes for patients lacking capacity to attend appointments. There is also a noted lack of readily available past medical and medication history for emergency crews.
Addressed to: Mildmay Medical Practice
AI-generated concerns summaryThe coroner identified a lack of ACCT initiation despite clear self-harm indications, an over-reliance on verbal information rather than documented risks, and an insufficiently robust system for capturing healthcare information, which resulted in a missed opportunity to restart antidepressant medication.
Addressed to: HM YOI Glen Parva; Leicestershire Partnership Trust
AI-generated concerns summaryThe coroner noted a delay in sending a urine sample for legionella analysis despite early recognition of atypical pneumonia, which may have delayed optimal treatment. Concerns were also raised regarding the lack of a rapid testing and reporting service for legionella.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified a lack of precision in the trust's communication protocols, noting that staff lacked clear instructions on how to action identified communication needs effectively.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that national police driver training requirements for night-time driving do not mandate practical in-car training, with some forces only offering classroom-based instruction.
Addressed to: Association of Chief Police Officers; College of Policing
AI-generated concerns summaryThe coroner identified an unreliable booking system for community INR testing, which led to appointments not being transferred, and an unreliable notification system for such omissions.
Addressed to: Cwm Taf University Health Board; National Assembly for Wales