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 coroner noted insufficient quality in information gathering and exchange among medical professionals, including an inadequate examination by a District Nurse and a lack of communication between hospital teams, which delayed specialist assessment.
Addressed to: Blackpool Teaching Hospital NHS Foundation Trust; Croft House Rest Home; Lancashire Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted staff lacked appreciation for respiratory depression risks in patients with co-occurring drug and alcohol problems. Admission procedures for alcohol detoxification also lacked drug screening, hindering proper risk assessment for those known to take other substances.
Addressed to: Priory Group Ltd
AI-generated concerns summaryThe coroner noted a limited exchange of mental health information between professionals in Cheshire and Blackpool, meaning Blackpool staff lacked a detailed understanding of the patient's recent presentation and risks upon his return.
Addressed to: Cheshire and Wirral Partnership NHS Foundation Trust; Lancashire Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted increased vulnerability following changes in services and funding. Additionally, hospital appointments sent to the patient's home were not followed up due to her insufficient understanding to deal with correspondence and care co-ordinators not being informed of missed appointments.
Addressed to: Walsall and Dudley Mental Health NHS Trust; West Midlands Police
AI-generated concerns summaryThe coroner noted the absence of an appropriate out-of-hours service for drug addiction, which placed an undue burden on emergency services. Concerns were also raised about the timeliness of follow-up checks for patients self-discharging after an overdose.
Addressed to: Bury Metropolitan Borough Council
AI-generated concerns summaryThe coroner raised concerns regarding the administration of medication to patients with known allergies without appropriate senior medical advice, and the need to ensure informed consent in such situations.
Addressed to: Frimley Park Hospital
AI-generated concerns summaryOut-patients returning to the fracture clinic were not re-assessed under the DVT policy, potentially increasing DVT risk. Additionally, delays in typing doctors' notes meant they were not always available for follow-up appointments.
Addressed to: Portsmouth Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted insufficient follow-up after Mr Harman was found soiled and that indicators of his deteriorating condition did not trigger a review beyond the annual schedule. Handover notes also lacked specific welfare check requests.
Addressed to: Centra Support
AI-generated concerns summaryThe coroner identified a lack of standard procedures to regularly remind employees of lifting plans, associated risks, and health and safety issues, which could lead to complacency. There was also limited evidence of recent "Toolbox Talks."
Addressed to: FALCON CRANE HIRE LIMITED
AI-generated concerns summaryThe report notes the absence of national governance, a lead, and disease-specific benchmarking for autologous stem cell transplant. Unreleased international trial results prevent clinicians from knowing normal recovery times, potentially affecting optimal care for children.
Addressed to: NHS England
AI-generated concerns summaryConcerns were raised about delays in securing an informal hospital admission for the patient and a lack of exploration of private bed options. Further concerns noted delays in arranging Mental Health Act assessments, with no clear protocols for timeframe or communication regarding urgent assessment options.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of an alarm on the oxygen concentrator to indicate a loss of oxygen flow if the humidifier screw cap was not properly engaged, along with insufficient training and literature on this specific risk.
Addressed to: Dolby Vivisol; Invacare Rehabilitation; Salter Labs
AI-generated concerns summaryThe coroner identified gaps in training for police and hospital staff regarding missing persons procedures and responsibilities. Ineffective communication between police and the hospital led to critical risk assessment information being omitted and reclassification not being communicated.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust; Surrey Police
AI-generated concerns summaryThe coroner noted a lack of formal systems at Freeman Hospital to record sudden medical interactions, meaning advice given by a specialist could not be traced or recalled. This advice appeared to have been given without reviewing the CT scan, which the coroner indicated could place patients at risk.
Addressed to: Newcastle Foundation NHS Trust
AI-generated concerns summaryThe Isle of Wight Ambulance Service did not appreciate the gravity of Loeys-Dietz syndrome and its predisposition to aortic aneurysms, which impacted their advice regarding hospital assessment.
Addressed to: Isle of Wight Ambulance Service; Isle of Wight NHS Trust
AI-generated concerns summaryThe coroner noted a lack of a system requiring the radiology department to either rectify a displaced urinary catheter or urgently report such findings to treating clinicians.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that patients undergoing ERCP surgery should be advised to contact the surgical department, not just their GP, if post-operative symptoms persist for more than 24 hours, as earlier medical attention could alter outcomes.
Addressed to: Walsall Healthcare NHS Trust
AI-generated concerns summaryNo falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
Addressed to: Cwm Taf Health Board
AI-generated concerns summaryPolice do not routinely check or provide damage-only road incident data to councils, which stopped being recorded in 2011 for unclear reasons. This data is not consistently considered when determining necessary highway maintenance works, despite its potential usefulness.
Addressed to: MGWSP; Northamptonshire County Council; Police Safer Roads Team
AI-generated concerns summaryThe coroner noted a lack of an effective bed bureau system and insufficient local child psychiatric beds, leading to placements far from home. This resulted in inadequate facilities, disrupted family therapy, and communication issues, which impacted patient care.
Addressed to: Devon Clinical Commissioning Group; NHS England