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 immediate transfer of a patient upon turning 18 was detrimental to her mental health, driven by statutory obligations rather than her best interests. The coroner also identified a lack of secure mental health care provisions for young adults aged 18-24 with similar complex clinical needs.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in the dissemination of Trust policy and NPSA guidance, weaknesses in staff training and checking for current competency in procedures. There was also insufficient knowledge regarding the number of trained staff available for such tasks.
Addressed to: Basildon Hospital NHS Trust
AI-generated concerns summaryConcerns were raised that out-of-hours staff did not immediately send the child to hospital for an infected umbilical cord, and a doctor later failed to appreciate the seriousness of the situation, sending the child home. The coroner also noted the GP surgery's lack of facilities for simple blood tests.
Addressed to: Bridgewater Community Healthcare NHS Trust
AI-generated concerns summaryConcerns included inadequate handling of medication, failure to obtain historical psychiatric records for a patient without a GP, and discharge deficiencies such as lacking direct mental health referral and appropriate clothing.
Addressed to: Barts NHS Trust; East London NHS Trust
AI-generated concerns summaryThe coroner noted insufficient staff training and monitoring, lack of clarity regarding rules for bed positioning and brakes, and inadequate information transfer among staff and with relatives. Concerns were also raised about appropriate staffing assessment and the allocation of nursing care.
Addressed to: Ayslebury Partnership; King's College Hospital NHS Foundation Trust; London Borough of Southwark (Housing Assessment and Support Service); Sunrise Senior Living
AI-generated concerns summaryThe coroner identified a service gap in inpatient psychological therapy due to a lack of qualified practitioners and resources. This resulted in an inability to refer inpatients to a psychologist, and long wait times for community referrals post-discharge left patients vulnerable.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a disparity in jet ski safety regulations for minors between the UK and the UAE, where a 14-year-old died unsupervised. Concerns were raised regarding clearer travel advice for British nationals about differing local safety standards for activities involving children.
Addressed to: Foreign, Commonwealth & Development Office
AI-generated concerns summaryThe Firearms Unit lacked access to secure police logs detailing domestic incidents involving a serving police officer during his shotgun licence renewal. The coroner suggests that restricted logs could be reviewed at a senior level to share relevant information with the Firearms Unit for assessment.
Addressed to: Devon and Cornwall Constabulary
AI-generated concerns summaryThe coroner identified concerns regarding the prescription and dispensing of an excessive paracetamol dose, a lack of subsequent dose review, and the failure to conduct blood tests that would have revealed this issue.
Addressed to: Mark Reynolds Solicitors; Royal Bolton Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient information sharing from the mental health team with other staff and that mental health input was not always given sufficient weight in ACCT reviews. Concerns were also raised that ACCT review members often did not read relevant documents beforehand.
Addressed to: Care UK; National Offender Management Service; Tees Esk Wear Valley NHS Foundation Trust
AI-generated concerns summaryThe prison lacked a clear policy for calling an ambulance, relying on subjective staff judgment, and had inconsistent recording of healthcare events, hindering effective handover and review.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryConcerns were raised regarding the insufficient number of first aiders available at Springhill site, particularly at night, and potential delays in healthcare staff moving between prison sites. There is also a lack of clear guidance for staff on when to commence CPR.
Addressed to: Springhill Prison
AI-generated concerns summaryThe coroner raises concerns regarding the need for detailed assessments of a patient's functional performance in their home circumstances post-discharge and the importance of adequate home support.
Addressed to: Peterborough and Stamford NHS Trust
AI-generated concerns summaryThe coroner noted the deceased was attacked by out-of-control dogs kept in confined conditions lacking enrichment. Concerns were raised that fragmented, breed-specific dog control legislation is ineffective in preventing bite incidents and causes confusion for law enforcement.
Addressed to: Department for Environment Food and Rural Affairs
AI-generated concerns summaryConcerns were raised regarding the advice provided by Community Mental Health Services to a GP, who sought guidance on a patient's deteriorating condition, to re-refer the patient to the Assessment and Treatment Service.
Addressed to: Brighton and Hove City Council; Community Governance; Sussex Partnership Trust
AI-generated concerns summaryThe coroner noted a correlation between deteriorating physical and mental health was not investigated by all mental health professionals. There was also a lack of documented review or revision of the care plan after the individual stopped engaging with services.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryA lack of a system for new GP practices to verify medication details for nursing home patients led to critical omissions. The coroner also noted concerns regarding unqualified staff confirming prescriptions, highlighting the need for a robust system from the Clinical Commissioning Group.
Addressed to: Bedfordshire Clinical Commissioning Group
AI-generated concerns summaryAn interruption in the electricity supply stopped the main oxygen apparatus, and there was no backup system to ensure continuous oxygen provision.
Addressed to: British Oxygen; Philips Respironics
AI-generated concerns summaryThe coroner noted a lack of mandatory and regular glucose testing for patients on antipsychotic medication by the Clozapine clinic.
Addressed to: Russell-Cooke solicitors; South London and Maudsley NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clear training for staff on when to deviate from psychiatric assessment pathways in the ED, and insufficient 24/7 access to patient medical records including Care and Treatment Plans. Concerns were also raised about the need for greater family engagement regarding crisis options.
Addressed to: Betsi Cadwaladr University Health Board