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 a lack of staff knowledge and inconsistent implementation of Trust protocols for managing bleeding related to thrombolytic therapy and massive blood loss.
Addressed to: Pennine Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified a potential inadequacy of resources within the Trust area to manage recognised complications arising during or after certain medical procedures, following three instances.
Addressed to: North Lincolnshire and Goole Hospitals NHS Trust
AI-generated concerns summaryConcerns were raised regarding the transfer of acute psychiatric patients when no beds are available, and the use of the Crisis Resolution and Home Treatment Team (CRHTT) as a filter preventing patients from accessing a bed.
Addressed to: Barnet Enfield and Haringey Mental health trust; Department of Health
AI-generated concerns summaryThe coroner identified the presence of exposed raised pipework, accessible to the public and potentially attached to bridges, which falls under the organisation's responsibility.
Addressed to: Association of Independent Gas Transporters; Northern Gas Network; Scotia Gas Network; Wales and West Utilities
AI-generated concerns summaryThe coroner noted the absence of specific aftercare leaflets provided to the patient, the consistent non-completion of the Thromboprophylaxis Risk Assessment form, and incomplete nursing notes and checklists at the point of discharge.
Addressed to: Norfolk and Norwich University Hospital NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the lack of a night-time equivalent of the Reducing Harm Team for additional staffing. The coroner is also concerned that a proposed reduction in night staff could compromise patient safety due to increased workloads.
Addressed to: Sherwood Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the absence of clear, written conditions for temporary hospital leave, including supervision responsibility and observation regimes, leading to conflicting expectations.
Addressed to: Greater Manchester West Mental Health NHS Foundation Trust
AI-generated concerns summaryA junior doctor performed the pre-operative assessment, leading to the consultant being unaware of vital information, and operation notes lacked details of equipment used. There were also insufficient junior doctors on duty, particularly at night.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the process for tracking and transferring a child's health records when a parent moves without providing new contact or GP details, leading to records being placed in 'No Trace storage'.
Addressed to: Integrated Children's Services, Coventry; Coventry and Warwickshire NHS Trust
AI-generated concerns summaryThe coroner noted that non-controlled drugs, including opiates, are not audited, posing a risk of potent medication being unaccounted for. There was also a lack of consistent understanding and methods among nursing staff for performing regular patient observations.
Addressed to: West London Mental Health NHS Trust
AI-generated concerns summaryThe coroner identified significant documentary failings in medication control at the Royal Orthopaedic Hospital, specifically the absence of an audit or paper trail for non-controlled medication, creating opportunity for misuse. The coroner suggested the Trust implement its own audit guidelines to address this gap.
Addressed to: Royal Orthopaedic Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient information sharing between clinical teams and HMPS staff regarding prisoner risk, and the absence of a senior clinician at discharge case reviews. There was also an identified unmet need for psychological therapies for prisoners with personality disorders.
Addressed to: MHSC; HMP Manchester; MHSC; Ministry of Justice; NHS England
AI-generated concerns summaryThe tractor involved in the collision did not display an amber warning beacon, which current regulations do not require on all roads. The coroner suggests considering whether the use of such beacons should apply to vehicles on all roads to enhance visibility and collision avoidance.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of awareness among healthcare practitioners, especially General Practitioners, regarding the significance of GDH positive results for Clostridium Difficile risk and future antibiotic prescriptions. Concerns were also raised about the absence of consistent procedures in hospitals nationwide for communicating these results to primary care providers.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of procedures for reviewing falls risk assessments and documentation following a fall or significant change in a resident's condition. Concerns also included issues with alarm systems for falls and call bells, and insufficient training for agency staff on relevant procedures.
Addressed to: Pindy Enterprises Limited
AI-generated concerns summaryThe report raises concerns about the lack of a system for training and supervising parents/carers in oxygen supply transfer. It also notes the absence of independent checks on oxygen apparatus functionality and carer competence before patient discharge.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of supervision for an operating surgeon using an inappropriate delivery technique, along with deficiencies in contemporaneous record-keeping and candour. The Serious Untoward Incident investigation was also deemed inadequate, with no disciplinary action taken.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a breakdown in communication between midwives regarding signs of respiratory distress, and the initial observation records were not retained. Parents were also not informed of concerns about their child's breathing, limiting their opportunity to contribute to care.
Addressed to: Lewisham and Greenwich NHS Trust
AI-generated concerns summaryConcerns were raised about the reliability of a 'tick in the box' system for consultant attendance and the impact of unavailable community medical records at the time of hospital admission.
Addressed to: Abertawe Bro Morgannwg University Health Board; National Assembly for Wales
AI-generated concerns summaryThe coroner noted concerns regarding GPs' interpretation of patient confidentiality, which prevented family members from sharing pertinent information about vulnerable individuals at risk.
Addressed to: NHS England