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 identified that the Early Warning Score (EWS) protocol was not followed and EWS training for nurses is not mandatory, despite its importance for patient well-being.
Addressed to: Southmead Hospital
AI-generated concerns summaryThe coroner identified issues with the care home's adherence to care plans, monitoring of resident health, and timely medical advice. Concerns also included incomplete wound documentation, delayed specialist referrals, and a lack of national guidelines for impact injury wounds.
Addressed to: Berrymans Lace Mawer LLP; Hempsons Solicitors; Leeds City Council; Leeds Community Healthcare NHS Trust; Moorfield House Surgery; NICE; Radcliffesle Brasseur LLP; St Armands Court Residential Care Home; Williamsons Solicitors
AI-generated concerns summaryThe patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Addressed to: Tameside NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that urgent requests for specialist care within the CICU department may be delayed or unanswered. This is due to procedures for CICU staff requesting assistance via the Hospital Switchboard being insufficiently robust.
Addressed to: Blackpool Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the difficulty for drivers exiting Llanwonno Road due to busy traffic, leading to risky manoeuvres, with poor visibility contributing to misjudgement. There have been nineteen other collisions on this road since 2001, including two fatalities.
Addressed to: Rhondda Cyon Taff Highways Department
AI-generated concerns summaryThe coroner noted a lack of clarity in procedures for arranging transportation for patients with complex medical issues, which could lead to necessary medical procedures being missed due to administrative issues.
Addressed to: Chalfont Road Surgery; Royal Free London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a mismatch in perception between Cleveland police officers and local A&E staff regarding the treatment of violent or aggressive patients with medical emergencies. There is a lack of dialogue and clear guidelines between the Constabulary and A&E departments to address these misunderstandings.
Addressed to: Cleveland Constabulary; IPCC; JCUH; NEAS; Tascor (formerly Reliance)
AI-generated concerns summaryThe coroner raised concerns regarding the overall safety of a junction, specifically citing the adequacy of speed restrictions and the frequency of grass cutting, which could potentially obscure drivers' views.
Addressed to: Sunderland City Council
AI-generated concerns summaryThe report identified a need for regular vigilance training for trackside maintenance crews, detailed briefings on train routes near stations, and a balance between hearing protection and the ability to hear oncoming trains.
Addressed to: Frisbys Solicitors; Kennedys Solicitors; Network Rail; Office of the Rail Regulator; Rail Accident Investigation Branch; Rail Maritime and Transport Union
AI-generated concerns summaryThe coroner noted that ECG information and traces from ambulance staff were not consistently recorded in A&E notes or routinely handed over to hospital staff upon patient arrival.
Addressed to: North West Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted two collisions at a specific location and raised concerns regarding pedestrian safety, identifying a need for improved phase indication to prevent unsafe crossing.
Addressed to: Sandwell Metropolitan Borough Council
AI-generated concerns summaryThe coroner raises concerns that the Medicines and Healthcare Products Regulatory Agency (MHRA) and NICE have not acted on recommendations to update product information warnings for anaesthetic agents and revise pre-operative assessment guidelines concerning Long QT Syndrome.
Addressed to: Derby Hospitals NHS Foundation Trust; Medicines and Healthcare Product Regulatory Agency; National Institute for Health and Care Excellence; National Patient Safety Agency
AI-generated concerns summaryInadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Addressed to: Coventry City Council
AI-generated concerns summaryMedical attention for the deceased was not sought or considered for 24 hours following a fall, despite the person experiencing pain.
Addressed to: Home Instead Senior Care
AI-generated concerns summaryThe coroner noted the lack of availability of psychological services within crisis teams and that not all teams have access to a psychologist. Concerns were raised about significant waiting times for psychological therapy, highlighting a need to prioritise cases.
Addressed to: Manchester Clinical Commissioning Group; Manchester Mental Health and Social Care Trust
AI-generated concerns summaryThe coroner raised concerns regarding the use of Cyclizine in patients with severe heart failure, noting cautions in the British National Formulary and the availability of an alternative antiemetic with a different cardiac risk profile.
Addressed to: College of Emergency Medicine; National Institute for Clinical Excellence
AI-generated concerns summaryThe coroner noted poor and non-existent patient records, including a lack of documented risk assessments. Concerns were also raised about the absence of a policy for staff when a patient requires admission but a bed is unavailable.
Addressed to: Priory Group
AI-generated concerns summaryThe coroner noted a lack of inpatient psychological support and confusion regarding outpatient referrals. Concerns were also raised about the Recovery Team's attendance at discharge meetings and insufficient communication of family concerns about the deceased's suicidal thoughts to the team.
Addressed to: 5 Boroughs Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that the current British Standard for steel palisade fences does not adequately address safe gate hinge design, specifically the practice of inverting an upper hinge pin which concentrates weight. An expert recommended the standard be changed to promote safer hinge arrangements.
Addressed to: Health and Safety Executive; Spaces and Places Limited; British Standards Institute
AI-generated concerns summaryThe coroner noted an inadequate discharge summary that failed to clarify medication status and the risks of late Friday discharges without assured weekend healthcare provision. Gaps in medication administration and venous thromboembolism risk assessments were also identified.
Addressed to: HMP Manchester; Mid Yorkshire Hospitals NHS Trust; High Security Prisons Group