Browse 6,493 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe care home's "Falls Risk Assessment" document incorrectly recorded no previous falls, despite evidence of multiple falls, which contributed to a delay in the person being taken to hospital.
Addressed to: Appleton Lodge Care Home
AI-generated concerns summaryThe coroner noted a history of several serious incidents, including three fatal ones, at a particular road junction. All fatal incidents involved vehicles turning right at this junction or from the northbound into the Dalton Piercy junction.
Addressed to: Hartlepool Borough Council; Highways Agency
AI-generated concerns summaryThe coroner noted concerns regarding inadequate training for GPs on electronic patient systems, leading to difficulty accessing important clinical information. The software also failed to alert users to significant diagnosed conditions when patient records were opened.
Addressed to: NHS England; NHS Wales; Royal College of General Practitioners; Welsh Assembly Government
AI-generated concerns summaryInappropriate discharge planning, insufficient training on bed rail use, and conflicting policies between hospital and community services regarding equipment provision were identified. The coroner also noted inadequate service coordination for equipment follow-up and an unimplemented communication alert system.
Addressed to: Leicester Partnership Trust; University Hospitals of Leicester
AI-generated concerns summaryThe coroner noted a lack of evidence that steps outlined in two action plans, created in response to Mr. Erdogan's death, had been completed by the stated deadlines prior to the inquest. This delay in implementation raises concerns about preventing future deaths.
Addressed to: Barnet Enfield and Haringey Mental Health NHS Trust
AI-generated concerns summaryAgency staff demonstrated insufficient understanding of hospital policies and procedures for medication administration, record-keeping on prescription charts and nursing notes, and correct patient handover procedures.
Addressed to: Mayday Health Care Plc
AI-generated concerns summaryThe coroner noted the absence of national guidelines for interpreting antenatal CTG tracings and raised concerns about the dissemination and application of the Trust's local interpreting policy, especially regarding informed consent.
Addressed to: Department of Health and Social Care; Pennine Acute Hospitals NHS Trust; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner identified the presence of organo-phosphate compounds in aircraft cabin air, noting potential health damage to occupants and flight controllers. Concerns were also raised regarding the lack of real-time monitoring and consideration of genetic variations in human tolerance to exposure.
Addressed to: British Airways; Civil Aviation Authority
AI-generated concerns summaryThe dispatch team lacked immediate visibility of incoming incidents, impacting their ability to respond. The coroner also asked Sainsbury's to consider their landowner responsibility for river safety, including providing a life buoy station.
Addressed to: Avon and Salisbury Constabulary; Bath and North East Somerset Local Authority; Sainsburys Plc
AI-generated concerns summaryThe coroner identified the absence of a VTE assessment for Mrs. Snape, attributed to staff workload and a belief it was unnecessary. This, along with insufficient consideration and knowledge of NICE guidelines for mechanical anti-DVT devices, presented missed opportunities in her care.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified a lack of proactive contact and follow-up by the care team after Mr Yarnell's discharge and relocation, including failing to make home visits or use known family contact details, resulting in a six-week gap in care.
Addressed to: Lancashire Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of shared understanding between general practitioners and the Islington Crisis Team regarding the team's capacity and whether it functions as an emergency service, recommending specific training for GPs on crisis team limitations.
Addressed to: Killick Street Health Centre
AI-generated concerns summaryConcerns include inadequate information handover, staff not reading patient notes before making critical decisions, and poor or outdated risk assessment documentation. The coroner also noted delayed patient reviews and the presence of non-ligature-proof doors.
Addressed to: Northamptonshire NHS Partnership Trust and Berrywood Hospital
AI-generated concerns summaryThe coroner noted that despite an action plan to provide advice to transport services on managing spontaneous haemorrhage, the volunteer driver involved in the incident had not received this specific training.
Addressed to: NSL Care Services
AI-generated concerns summaryThe coroner noted instances where family found the patient in need of changing with delays in nurse assistance, and questioned a nurse's suggestion of private care. Additionally, there was an unexplained five-hour delay in a consultant review for a patient with a low Glasgow Coma Score.
Addressed to: Barts Health
AI-generated concerns summaryThe coroner noted the risk of injury to residents from inward-opening toilet cubicle doors in care settings, particularly if a resident is slumped forward. This design contrasts with guidance for disabled toilets suggesting outward-opening doors.
Addressed to: Bury Metropolitan Borough Council; Care Quality Commission; Department of Health and Social Care; Messrs. Latimer Lee Solicitors; Oak Lodge Care Home
AI-generated concerns summaryBasic patient observations were repeatedly unrecorded, with no senior review to detect shortfalls or written rationale for observation frequency. Additionally, the coroner noted no reporting system for professionals not meeting accepted standards.
Addressed to: University Hospitals Leicester
AI-generated concerns summaryThe coroner noted an absence of guidance for the effective cleaning of fixed shower heads, which are increasingly used in private and public leisure facilities.
Addressed to: Doncaster Borough Council; Health and Safety Executive
AI-generated concerns summaryThe coroner noted the undesirable practice of sending 8 to 12 psychiatric patients out of county monthly due to a lack of acute beds, identifying a risk that this could lead to a future death.
Addressed to: Department of Health and Social Care; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that existing warning signs about a particularly deep pool and strong currents in the River Wear were inadequate and not visible from both riverbanks, raising concerns about public awareness of the dangers.
Addressed to: Durham County Council; Finchale Abbey Farm