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 noted that social workers did not record the rationale for downgrading a client's self-harm risk, as it was not a routine requirement. There was also a suggestion for more training and support for Shared Lives Carers working with clients with mental health problems.
Addressed to: Hampshire County Council
AI-generated concerns summarySuboptimal clinical care regarding pneumothorax management and medication was noted. Other concerns included communication gaps, procedural errors before aspiration, confusing medical records, and insufficient consultant on-call respiratory cover.
Addressed to: East Kent Hospital University NHS Trust
AI-generated concerns summaryThe road surface treatment did not adhere to adverse weather guidance, and the Route Steward had not reported running water across the carriageway at the location.
Addressed to: South Wales Trunk Road Agent
AI-generated concerns summaryNational guidelines for warnings given to patients prescribed certain antidepressants do not currently include the risk of severe seizures, a known potential side effect of these medications.
Addressed to: National Patient Safety Agency
AI-generated concerns summaryThe coroner identified inadequate telephone assessment of new symptoms and insufficient mental state exploration and risk assessment. Concerns were also raised about gaps in Trust policy regarding home visits and detailed non-in-person assessments.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryConcerns include insufficient information for migrant populations about road nature, lack of encouragement for reflective clothing, and the absence of footpaths, lighting, and speed restrictions in a populated area.
Addressed to: Billington Farm; Staffordshire County Council; Staffordshire Police; The Chief Coroner
AI-generated concerns summaryThe coroner noted that the NHS Trust did not require its recruitment agency to perform registration or fitness-to-practice checks on a locum doctor. The Trust was also unaware of prior concerns and ongoing investigations regarding the doctor's performance in other health services.
Addressed to: Department of Health and Social Care; General Medical Council; NHS England; University Hospital Lewisham
AI-generated concerns summaryA brain scan was misinterpreted after being viewed by a general radiologist instead of a neuro-radiologist, despite guidelines for specialist review. The coroner suggested reviewing the protocol for scans viewed by non-specialists.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted a continued risk of prescribing errors within the Trust due to the absence of an electronic prescribing system, seeking reassurance and a clear timeline for its introduction.
Addressed to: Royal United Hospital
AI-generated concerns summaryThe Snowdonia National Park Authority has not implemented advice from the Llanberis Mountain Rescue Team to address misleading paths near Snowdon's summit, which the coroner notes creates perilous situations for walkers.
Addressed to: Snowdonia National Park Authority
AI-generated concerns summaryThe coroner noted difficulties in managing patients with both psychiatric illness and ADHD when their treatment is split between two geographically distant hospitals.
Addressed to: Bedfordshire Clinical Commissioning Group
AI-generated concerns summaryA reduction in the number of prison officers at HMP Woodhill by one third may compromise prisoner safety and put lives at risk, according to evidence provided by a Governor.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner identified that the clinical specialist did not directly ask the patient about suicidal thoughts or illicit medication use. There was also no exploration of therapeutic benefit from an alternative healthcare professional despite poor rapport and shortened sessions.
Addressed to: Camden and Islington NHS Foundation Trust
AI-generated concerns summaryMr Sonagara had multiple unamalgamated medical records under different hospital numbers, and a temporary file was not incorporated into his permanent record. This meant treating doctors were unaware of potentially relevant information in these separate records.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryConcerns relate to inadequate visibility and training for temporary traffic light placement, along with the absence of clear police and council procedures for identifying and addressing road safety risks.
Addressed to: Department for Transport; Reigate and Banstead Council; Surrey Police; Sutton and East Surrey Water Plc
AI-generated concerns summaryAn optician's assessment of the deceased's driving vision standards differed from a DVLA review. The coroner noted the optician did not advise the deceased to report vision defects to the DVLA, leading to continued driving without regulatory reassessment.
Addressed to: Buckinghamshire Healthcare NHS Trust; General Optical Council
AI-generated concerns summaryThe GP practice lacked a system to review abnormal blood test results and initiate patient treatment, leading to a delay of over 24 hours before results were reviewed after the family insisted on an appointment.
Addressed to: Surgery Chesterton
AI-generated concerns summaryNo neurological observations were made between 5am and 1:15pm on 3rd April, despite the patient experiencing two falls, one of which resulted in a facial injury.
Addressed to: Cwm Taff Health Board
AI-generated concerns summaryAn abdominal X-ray report was not seen by doctors, leading to diagnosis without full information and inappropriate discharge; GPs were also unaware of its content. Additionally, the patient was discharged without prescribed medication and no discharge summary was sent to their GP.
Addressed to: Shrewsbury and Telford Hospital NHS Trust
AI-generated concerns summaryThe NNUH discharge letter contained inaccuracies, and there was a lack of awareness regarding prior concerns about the care home's suitability for the patient's deteriorating condition, leading to an inappropriate discharge. Delayed assessments also lacked essential nursing information.
Addressed to: Norfolk and Norwich University Hospital NHS Foundation Trust; Norfolk Community Health and Care NHS Trust; Norfolk County Council