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 an absence of guidance for optimal thromboprophylaxis management in patients with restricted mobility due to a brace, particularly when they are not in casts.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryAn outdated on-call rota used by the hospital switchboard caused delays in contacting the correct consultant for an emergency endoscopy. The coroner identifies a need for an up-to-date, centrally managed rota accessible to all relevant staff.
Addressed to: University Hospitals of Leicester NHS Trust
AI-generated concerns summaryConcerns were raised about a suggestion of 'assisted self-harming' to a high-risk patient lacking evidence from published research or proper procedures for novel treatments. The discussion was also not communicated to the consultant psychiatrist nor recorded.
Addressed to: Avon and Wiltshire Mental Health Partnership NHS Trust; Care Quality Commission
AI-generated concerns summaryThe coroner noted concerns that the falls risk assessment form does not presume increased risk for certain patient classes, which could lead to misclassification and potentially different outcomes.
Addressed to: County Durham and Darlington NHS Foundation Trust
AI-generated concerns summaryThe coroner identified fragmented patient case notes and queried plans for immediate electronic access, alongside the need for a national policy for engagement and observation. Concerns were also raised regarding updated guidance for the treatment and management of Borderline Personality Disorder.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of written policy for 'no treats' and insufficient first aid training for health support workers. There was also no policy ensuring a first aid trained member of staff on every shift.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner identified concerns regarding significant ward understaffing, which led to one nurse caring for 16 patients and performing a drug round alone. Additionally, the report noted a lack of out-of-hours doctor cover at St George's Hospital.
Addressed to: South Staffordshire and Shropshire NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that Newham Council's communication methods did not accommodate the deceased's difficulties with age, mental awareness, and lack of modern technology skills, preventing him from addressing his debt. This lack of accessible communication contributed to the events leading to his death.
Addressed to: Newham Council
AI-generated concerns summaryThe coroner noted inconsistencies in patient assessment approaches among clinicians and suggested that nationally agreed standard forms would improve communication when patients are transferred between different mental health care providers.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a fault, which may not be revealed by electric testing, could be present in other similar properties and suggested the Fire and Rescue Service consider how to alert the local community.
Addressed to: Fire and Rescue Oxfordshire
AI-generated concerns summaryThe coroner raised concerns regarding the lack of written handover between supervisors, inaccurate detail in records, and the daily log being inaccessible and misleading, hindering the passage of significant medical information.
Addressed to: St Edward’s School
AI-generated concerns summaryThe coroner identified a lack of pedestrian protection on the bridge, specifically no central fence or reservation. Concerns were also raised about low and uneven street lighting, and headlight glare obscuring pedestrians from drivers' view at night.
Addressed to: Department for Transport; London Borough of Lambeth; City of Westminster; Transport for London
AI-generated concerns summarySheffield Children's and Leeds Teaching Hospitals NHS Trusts lack specific policies for paediatric oesophageal varix banding, and there are no national guidelines for this procedure, leading to varied practices among consultants.
Addressed to: British Society of Paediatric Gastroenterology; Leeds Teaching Hospitals NHS Trust; NHS Improving Quality; Sheffield Children’s NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in information transfer between child and adult mental health teams and insufficient ward staffing. Concerns included the ward's door policy and staff training on absconding, Section 136 procedures, and powers of detention.
Addressed to: Hywel Dda University Health Board
AI-generated concerns summaryThe coroner raises concerns about the inconsistent recording of information from patients presenting with mental health issues, specifically regarding the perceived level of risk and urgency for assessment. There were also conflicting accounts about the division of responsibilities and the urgency of care between different mental health services.
Addressed to: Avon and Wiltshire NHS Mental Health Partnership Trust; Department of Health and Social Care; Ministry of Defence; Public Health England; Salisbury Hospital NHS Trust; Great Western Hospital NHS Trust
AI-generated concerns summaryThe Care Agency did not determine the outcome of a swallowing assessment or implement steps to protect Mr Lyons from choking, and the care plan lacked a management strategy including supervision and specific food preparation instructions for carers.
Addressed to: John Stanley Agency
AI-generated concerns summaryMr Dack missed follow-up appointments due to an incorrect address in his medical notes, despite staff being notified twice. The coroner identified this as a recurring administrative issue needing a review of the hospital's system for managing patient addresses.
Addressed to: Barts Health
AI-generated concerns summaryThe coroner identified a lack of communication between the Trust and other agencies, exacerbated by the absence of a dedicated Care Co-ordinator for patients with complex needs.
Addressed to: Cumbria Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a specific risk assessment for suicidal ideation and a lack of formal communication mechanisms between mental health outpatient and acute services. Additionally, there was no reliable system for a crisis team member to take responsibility for assistance, and no clinical recordings of contact with …
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryThe coroner raised concerns about an elderly patient with a broken leg being advised to take a taxi to hospital due to ambulance resource shortages. Insufficient ambulances and staff, exacerbated by A&E delays and bed blocking, were noted as issues requiring central government action.
Addressed to: Department of Health and Social Care