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 summaryInadequate overnight supervision meant carers did not check the patient for several hours, despite an expectation of constant presence. Furthermore, carers had received theoretical but no practical training for their specific duties.
Addressed to: Care Quality Commission
AI-generated concerns summaryConcerns were raised regarding the unsafe transfer of a severely ill patient between hospitals in the early hours of the morning, with the coroner noting that ambulance shortages during the day should not be a valid excuse for such timing.
Addressed to: N.W.A.S. NHS Trust; Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner identified significant delays in doctor assessment and documentation of X-ray results in the Emergency Department due to staff busyness. There were also considerable delays in imaging result reporting, which nearly led to the discharge of a patient with a multi-fractured pelvis.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns include a lack of training for emergency medical dispatch staff on respiratory difficulty signs and the absence of a requirement to inform managers of unilateral crew stand-offs. Additionally, there is no system to automatically consider all alternative support methods during stand-offs.
Addressed to: Department of Health and Social Care; Yorkshire Ambulance Service
AI-generated concerns summaryThe coroner noted individuals can be left with no money in their bank accounts after payday lenders clear them out, suggesting a statutory minimum amount should remain to prevent destitution and potential future deaths.
Addressed to: Financial Conduct Authority
AI-generated concerns summaryThe coroner noted concerns regarding the hospital's Early Warning Observation Chart system, specifically its incorrect completion, ignored triggers, and lack of review by qualified staff. There is also no regular audit system to ensure proper use of the charts.
Addressed to: Milton Keynes Hospital
AI-generated concerns summaryThe coroner noted inadequate documentation, insufficient observation and monitoring, and shortcomings in assessing and planning for Mrs. Crossley's discharge, compounded by poor communication among her care providers.
Addressed to: University Hospitals Leicester
AI-generated concerns summaryThe coroner noted a lack of nursing care, poor communication regarding Mrs. Sandever's diabetes, and that she was left without intravenous fluids despite renal failure. Additionally, the hospital's investigation into these issues was deemed insufficient.
Addressed to: Hinchingbrooke Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the practice of placing tyres with less tread depth on the rear of vehicles, which contributed to aquaplaning, and the lack of awareness among police officers about their statutory powers to close hazardous roads.
Addressed to: Department for Transport; Derbyshire
AI-generated concerns summaryConcerns were noted regarding inadequate night staffing on healthcare wards, which compromises the ability to conduct effective ACCT observations and affects staff welfare due to staff not taking breaks.
Addressed to: Birmingham and Solihull Mental Health Trust; Birmingham Prison
AI-generated concerns summaryAn incomplete management plan on admission led to the patient being wrongly identified as not a falls risk, resulting in a 10-day delay for a full falls assessment. The coroner also noted poor record keeping.
Addressed to: East Surrey Hospital Trust
AI-generated concerns summaryThe coroner identified gaps in mental health assessments and 'step-down' support for young people in custody or transitioning from adult mental health services. Concerns also included insufficient information sharing between agencies and the incorrect classification of homeless young persons, affecting proper support.
Addressed to: Department for Education; GEOAmey; South Yorkshire Police; Youth Justice Board
AI-generated concerns summaryThe coroner identified a lack of clear leadership and sufficient staffing on the ward. Additionally, there were no clear protocols for handling lost patient notes or for managing blood sugar monitoring, insulin administration, and escalation of care for hyperglycaemic patients.
Addressed to: Royal Free London NHS Trust
AI-generated concerns summaryThe coroner identified a breakdown in communication and a lack of standardised documentation, recommending a review of referral methods for seriously ill patients between hospitals to improve clarity.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that hospital procedures were insufficiently robust and staffing levels did not provide enough resilience to minimise the risk of further deaths in similar circumstances.
Addressed to: Blackpool Teaching Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted missing records for intentional rounding checks and hourly neurological observations. Concerns were raised that consultant-stipulated neurological assessments and physiotherapy were not completed before discharge, alongside communication gaps about discharge readiness.
Addressed to: Barts Health
AI-generated concerns summaryThe coroner noted the absence of a formal self-harm or suicide risk assessment for Mr. Farrar upon his admission to Woodhill Prison, despite clear risk factors, and the general lack of such assessment tools in prisons.
Addressed to: Ministry of Justice; Secretary of State for Health
AI-generated concerns summaryThe coroner identified gaps in recording Lauren's contact information and sharing high-risk details (solvent abuse, sexual exploitation vulnerability) with the Missing Person's Unit, which hindered an effective search and delayed a multi-agency strategy meeting.
Addressed to: Bexley Social Services; Ethelbert’s Children’s Services; Metropolitan Police Service
AI-generated concerns summaryThe coroner identified difficulties in providing adequate nursing care, including errors in temperature measurement and incorrect medication application. These issues were attributed to insufficient nursing staff levels, recruitment challenges, and training funding problems.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryNo specific concerns were detailed in the provided text for this report.
Addressed to: Brighton and Sussex University Hospitals