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 raised concerns that Partnership In Care's current observation policy for patients in seclusion, which follows the Mental Health Act Code of Practice, is insufficient to prevent future deaths, unlike their prior higher standard policies.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a need to consider NICE guidance on late-onset sepsis in babies under 1500g and for further research into infection monitoring systems like HeRO.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the need for consideration of further legislation regarding a specific point identified during the inquest.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a design and maintenance issue allowing a trolley's cot side to remain raised but unlocked, with uncertainty about its inclusion in maintenance schedules. It was also noted the MHRA did not escalate this known risk to other hospital trusts.
Addressed to: Anetic Aid Limited; Medicines and Healthcare Products Regulatory Agency; Royal Berkshire Hospital Trust
AI-generated concerns summaryThe coroner identified concerns regarding the absence of forensic psychiatric assessments for vulnerable children entering custody, deficiencies in the ACCT process regarding external agency input and interpretation of distress, and issues with social worker allocation and documentation practices.
Addressed to: HMP Cookham Wood; Medway Youth Offending Team; Ministry of Justice; Oxleas NHS Foundation Trust; Tower Hamlets Council
AI-generated concerns summaryThe coroner raised concerns that risks of bleeding and vascular damage after pacemaker insertion were not fully investigated despite the patient developing chest pain. An echocardiogram showing a bleed was significantly delayed and its results were not available before the patient's death.
Addressed to: Queen Elizabeth Hospital
AI-generated concerns summaryThe coroner identified inadequate staffing levels at Harry Sotnick House, which meant residents in communal areas were not supervised at all times.
Addressed to: Care UK; Harry Sotnick House; Portsmouth City Council
AI-generated concerns summaryCare home staff did not perform CPR when the deceased collapsed, and there was no process or procedure in place to ensure resuscitation during an emergency.
Addressed to: BUPA Ardenlea Grove Nursing Home
AI-generated concerns summaryThe coroner noted the bus design lacked a barrier in front of the right-hand front seat where Mr. Gurton was seated.
Addressed to: First Essex Buses
AI-generated concerns summaryThe coroner raised concerns about the lack of clear directives for care staff on promptly seeking medical advice for residents' pain, particularly cardiac. Further issues included the need for formalised, regular staff training and improved accuracy and management oversight of record-keeping.
Addressed to: Quality Care Commission; South Tyneside Council
AI-generated concerns summaryThe coroner noted slow response times for Tissue Viability Nurse input and inadequate wound care, attributed to specialist nurses not being hospital-based and an insufficient number of TVNs in the region.
Addressed to: Cwm Taf University health Board, Medicine & Accident and Emergency Cwm taf UHB ad NWSSP Legal & Risk Service
AI-generated concerns summaryThe coroner identified that long, complex 999 and 111 calls were not available for audit by the CCG to improve outcomes. Concerns were also raised about call takers being able to downgrade calls to a lower acuity pathway.
Addressed to: NHS England; North West Collaborative Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that UK hospitals may be unaware of the requirement to accept EU-trained doctors' qualifications, potentially leading to these doctors practicing unsupervised and increasing patient risk.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that intelligence on the nature and duration of pistol hits was not accurately circulated, leading to commanders being misinformed. Greater consideration may be needed before clearing threat warnings from routes.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner raised concerns regarding the high number of accidents involving slow-moving vehicles at a specific road location, noting that existing warning signage appeared insufficient.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted an unusually high number of road incidents at a specific location, likely due to excessive speed, despite new signage. Consideration should be given to implementing a restricted speed area.
Addressed to: Powys County Council
AI-generated concerns summaryThe coroner noted a need to review and redesign the Prisoner Escort Record. Concerns were also raised about the availability of Wing System medical records in reception areas at HMP North Sea Camp and HMP Lincoln.
Addressed to: HMP Lincoln; HMP North Sea Camp; National Offender Management Service; NHS England; Nottinghamshire Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified insufficient transmission of comprehensive donor information and microbiology reports to the transplant centre. Concerns also included the accepting consultant not using the full electronic system and making unilateral decisions without a team approach.
Addressed to: NHS Blood and Transplant; University Hospital of Wales
AI-generated concerns summaryConcerns were raised about the quality of the PPO's investigation, specifically regarding inaccurate attendance records at a segregation review hearing. Such errors could impede the learning of lessons from similar cases.
Addressed to: Ministry of Justice; National Offender Management Service; Prison and Probation Ombudsman
AI-generated concerns summaryThe coroner identified insufficient documentation and escalation of telephone contact attempts, significant delays in reaching Mr Hayes, and that his presenting risks were not fully considered. Relevant healthcare and support agencies were not contacted when direct communication failed.
Addressed to: Norfolk County Council