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 summaryEmergency Department staff lacked awareness and training on the Trust's restraint policy and the dangers of prone restraint. There were also gaps in the availability of rapid tranquilisation medication, awareness of alternatives, and adherence to NICE guidelines.
Addressed to: Leicester University Hospitals NHS Trust
AI-generated concerns summaryThe A285 is an ancient, high-risk rural road that does not meet modern design standards. A specific entrance on the road is unlit, has limited sightlines, and an unmade surface, leading drivers to slow and risk collisions.
Addressed to: West Sussex County Council
AI-generated concerns summaryThe coroner noted inadequate diagnosis and treatment of Mr Colton's developing cancer at the prison, insufficient provision of pain medication, and a lack of continuity of care and communication among healthcare staff, exacerbated by GP workload.
Addressed to: HMP Long Lartin Healthcare; Worcestershire Health and Care Trust
AI-generated concerns summaryThe coroner noted a delay in a child receiving required CBT and sought assurances that this therapy would be available to children in a timely manner from North Bristol NHS Trust.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryInsufficient communication among staff regarding the patient's falls history, use of an out-of-date post-falls checklist, and inconsistent or incorrect recording of neurological observations were identified.
Addressed to: North Devon Healthcare NHS Trust; South Molton Community Hospital; South Molton Health Care Centre
AI-generated concerns summaryInadequate and incomplete nursing and medical records were identified regarding patient observations, medication administration, and an incident. A junior doctor declined a senior medical review despite a senior nurse's concerns about patient deterioration.
Addressed to: Huddersfield Royal Infirmary
AI-generated concerns summaryInsufficient monitoring and medical review for a high-risk patient led to a failure in following instructions for repeat blood tests and checks. The report also highlights a lack of clear action to address concerns about handover of responsibilities between shifts.
Addressed to: Barts Health
AI-generated concerns summaryConcerns were identified regarding the discharge of a patient with a mental health history without formal handover, a recorded reason, or agreement from the community team, and that no formal Serious Incident Investigation followed.
Addressed to: South Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryConcerns identified include un-actioned recommendations for support workers and carer assessments, internal communication gaps regarding appointments, and a patient's discharge despite failed contact and without addressing practical barriers to care.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a misunderstanding between the CMHT and the DCC Recovery Team regarding the latter's adherence to the Care Programme Approach (CPA) and the roles of its lead professionals as care co-ordinators. This led to a lack of clarity concerning responsibilities and service frameworks.
Addressed to: Derbyshire County Council; Derbyshire Healthcare NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner identified that medication prescribing did not sufficiently account for a patient's overdose history, and a computer warning system for practitioners was absent. Concerns were also raised about the lack of implementation and auditing of an action plan from a Root Cause Analysis.
Addressed to: Axminster Medical Practice; Devon Partnership NHS Trust
AI-generated concerns summaryThe coroner noted the absence of on-site medical assistance, delayed emergency response, inadequate ventilation, and unregulated fire exits at an unlicensed rave. The report also identified police's limited powers to proactively prevent such events in squatted commercial premises and insufficient resources for intervention.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that manufacturers producing medications in almost identical packaging may contribute to dispensing errors and potentially to patient deaths.
Addressed to: Crescent Pharma Ltd; Department of Health and Social Care; General Pharmaceutical Council; Medicines and Healthcare products Regulatory Agency; NHS England; Royal Pharmaceutical Society
AI-generated concerns summaryInsufficient precision in the surgical term 'nephroureterectomy' led to clinician misunderstanding of the procedure's extent. Additionally, there was no designated case manager to monitor the patient's progress and coordinate care in a complex case.
Addressed to: Department of Health and Social Care; Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryWelfare checks failed to ascertain the prisoner had died. There is no computer system to track non-attendance for prescriptions or lapsed prescriptions, and no policy for 24-hour medical observation in prisons without constant supervision.
Addressed to: HM Prison and Probation Service; NHS England
AI-generated concerns summaryThe coroner identified the lack of a sign warning motorists of a concealed entrance, particularly for traffic approaching from the Coleshill direction.
Addressed to: Warwickshire City Council
AI-generated concerns summaryThe coroner noted that non-injury collisions at the scene were not recorded, and that the 60mph speed limit on the B1192 through Brothertoft village was inappropriate given residential properties, suggesting a 30mph limit would be more suitable.
Addressed to: North LCC Highways; North Lincolnshire Council
AI-generated concerns summaryAgency staff lacked information and adequate induction to identify residents, resulting in an incorrect file retrieval and potentially inappropriate treatment. Resident rooms were also not clearly marked, which could lead to identification confusion during emergencies.
Addressed to: Bamford Grange Nursing Home
AI-generated concerns summaryThe coroner noted a failure to action and treat mental health referrals as urgent, identifying a lack of service-wide definitions for terms like 'urgent' and no agreed timeframes for referral action. This represented a lost opportunity for timely intervention.
Addressed to: Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner identified a lack of guidance for GPs on managing patients who do not collect medication required for their mental health conditions.
Addressed to: Department of Health and Social Care