Browse 6,493 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryCare staff were unaware of the increased bleeding risk for elderly patients on warfarin after a head injury. There was no clear policy or training for managing patients on anti-coagulants following a fall, or for escalating incidents to medical staff.
Addressed to: Care Quality Commission; Lapal House and Lodge Care Home
AI-generated concerns summaryThe coroner noted a lack of oxygen saturation monitoring during the patient's first hospital visit and upon discharge, and that previous oxygen level records were unavailable on re-admission.
Addressed to: Tameside Hospital Foundation NHS Trust
AI-generated concerns summaryHealthcare staff did not follow instructions to obtain blood and urine samples for a possible cancer investigation, nor did they act on recommendations for INR monitoring samples. There was also a failure to conduct a Significant Event Analysis regarding the death, as recommended by the Clinical Reviewer.
Addressed to: Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner noted insufficient challenge to Mr Holt's minimised suicidal intent and poor information flow, notably staff being unaware of his recent self-harm attempt. This led to inadequate risk assessment and disrupted care continuity.
Addressed to: Sheffield Health and Social Care Trust
AI-generated concerns summaryThe coroner identified delays in resolving clinical disputes between organisations due to differing treatment thresholds, which created a gap in service provision. Difficulties with the transfer of medical notes and records were also noted.
Addressed to: Department of Health and Social Care; Kernow Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted an unguarded cafe platform edge with a metre drop, posing a fall risk, particularly for children or those in buggies, a risk exacerbated by an incline. The planning department had not required a safety barrier.
Addressed to: Isle of Wight Council; Off the Rails Cafe; Owner of the "Off The Rails Café" site
AI-generated concerns summaryThe coroner noted a lack of communication between hospital wards regarding a patient's disclosure of a self-harm attempt, which appeared to be influenced by a concern about perceived blame between staff.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the lack of an auditing process for the new mental health referral system, as well as the absence of clear written policies for increased patient observations and for clinical reviews responding to new risks. The report also notes the importance of reminding staff about record-keeping …
Addressed to: Clinical Commissioning Group for South Central and North Manchester; Department of Health and Social Care; Greater Manchester West Mental Health NHS Foundation Trust; Manchester Mental Health and Social Care NHS Trust; NHS England; University of South Manchester NHS Foundation Trust
AI-generated concerns summaryThe staff nurse did not know the location for a Code Blue emergency, and prison officers who responded lacked recent CPR training due to resource limitations which created gaps in trained personnel.
Addressed to: HMP Norwich; Serco; Virgin Care Limited
AI-generated concerns summaryThe coroner noted insufficient action by Norfolk County Council to address long-standing safety concerns at a busy bus stop on the A148, despite previous issues being raised and a feasibility study for safety measures being conducted without implementation.
Addressed to: Norfolk County Council
AI-generated concerns summaryConcerns are raised regarding the security of the airlock system, which has allowed patients to 'tailgate' visitors and leave the unit. The report also notes a lack of monitoring by staff in the reception area.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that staff practice for Level 1 observations did not specify patient whereabouts beyond 'on the ward,' despite policy requirements. The report also notes a lack of clear evidence regarding staff training and development to minimise future risks.
Addressed to: Cheshire and Wirral Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the river estuary part of Aberffraw beach can be subject to very strong currents, of which the public are unaware without local knowledge. The report suggests erecting signs to warn the public of this potential danger.
Addressed to: Ynys Mon County Council
AI-generated concerns summaryThe report notes that the triage nurse did not see the ambulance patient report form and a locum doctor lacked access to complete computerised patient information. There were also concerns that necessary neurological observations were not instituted and an unnecessary CT scan was performed.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a significant delay between the request for a Deprivation of Liberty Safeguarding Best Interests Assessment in October 2014 and its completion in January 2015, despite the Local Authority's awareness of the deceased's urgent needs.
Addressed to: Central Bedfordshire Council
AI-generated concerns summaryThe coroner noted insufficient awareness among GP practices in Wales regarding NICE guidelines for head injuries in patients on warfarin, which recommend immediate hospital admission and CT scanning.
Addressed to: NHS Wales
AI-generated concerns summaryThe coroner noted the similar appearance of PEJ and PEG tubes could lead to confusion, suggesting a simple colour coding system to aid differentiation when the tubes are in situ.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted insufficient consultation with family/carers when detained patients return from leave, often limited to a few words in the patient's presence. There is also no system for a thorough mental state assessment of the patient upon their return to the unit.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryInsufficient medical cover and high activity on the labour ward led to delays in patient review, documentation errors, and communication gaps between clinical teams. The coroner also noted no system existed for theatre staff to proactively notify treating teams of theatre availability.
Addressed to: Queen’s Hospital
AI-generated concerns summaryInadequate post-operative fluid balance assessment, monitoring, and recording, alongside insufficient nursing records, were identified. The coroner also noted a failure to recognise the patient's acute illness and respond to family concerns.
Addressed to: East Surrey Hospital