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 concerns that paramedics may not be fully aware that Methadone's respiratory depressive effects last longer than Naloxone's antagonism, which could lead to a lack of repeat treatment doses when opiates are still active.
Addressed to: South West Ambulance Service
AI-generated concerns summaryThe coroner raised concerns regarding the absence of communication means within the canal tunnel, the lack of a requirement for all persons to wear safety jackets or buoyancy aids, and insufficient safety information provided to all passengers.
Addressed to: Canal and River Trust
AI-generated concerns summaryThe coroner noted it was not standard practice at Harrogate District Hospital to routinely administer chemical thrombo prophylaxis or undertake formal venous thromboembolism risk assessments for patients with conservatively treated lower limb injuries in casts.
Addressed to: Harrogate District Hospital
AI-generated concerns summaryThe coroner identified issues with the process of chest drain insertion, including incorrect labelling and misinterpretation of chest X-rays, the failure to consider both X-rays, and a lack of patient examination prior to the procedure.
Addressed to: College of Emergency Medicine; Department of Health and Social Care; British Thoracic Society; Royal College of Anaesthetists
AI-generated concerns summaryThe coroner raised concerns regarding the psychiatric assessment of Mrs. Thurman, specifically that a caregiver was not permitted to contribute and the patient was asked in a suggestive manner if she was content to be seen alone.
Addressed to: Dudley and Walsall NHS Mental Health Trust
AI-generated concerns summaryThe coroner noted insufficient staff First Aid training for responding to choking incidents and a lack of clear leadership during emergencies. There were also delays in reporting incidents under RIDDOR guidance.
Addressed to: Harbour Healthcare; United Care (North) Limited
AI-generated concerns summaryThe coroner noted that some staff in caring roles at the residential unit had not received basic life support training, or their training was out-of-date, highlighting a need for regular updates.
Addressed to: Hywel Dda University Health Board
AI-generated concerns summaryMidwives were not contactable for a booked home birth, resulting in family members assisting with the delivery before midwives arrived after the birth.
Addressed to: Central Manchester NHS Foundation Trust
AI-generated concerns summaryThe Medical Priority Dispatch System does not include methadone as an overdose drug choice or ask if a patient is alone. There were also concerns about a three-hour delay in paramedic response to an overdose call and a lack of appropriate follow-up after failed welfare checks.
Addressed to: London Ambulance Service NHS Trust
AI-generated concerns summaryThe low-level design of Queensgate Car Parks and other city centre car park walls does not effectively prevent individuals from jumping. This design contrasts with modern car parks and poses a risk to both individuals and pedestrians below.
Addressed to: Hammerson Plc; Pelican Partners Ltd; Peterborough City Council
AI-generated concerns summaryIncompatible computer systems prevented out-of-hours doctors from accessing the patient's full medical records, impacting treatment decisions and leading to a missed opportunity for escalation of care.
Addressed to: Local Care Direct organisation; Sheridan Teal House
AI-generated concerns summaryThe report describes unreliable and inaccurate patient observations, insufficient staff first aid training and response to a medical emergency, and questions the impact of 13.5-hour shifts on care quality.
Addressed to: Baron’s Park Nursing Home
AI-generated concerns summaryThe coroner identified that performing a gastric bypass on a patient with a hernia risked strangulation, leading to death. The report noted a need to disseminate nationally the surgeon's learning that a sleeve gastrectomy is a safer alternative for such patients.
Addressed to: University College Hospital
AI-generated concerns summaryThe coroner identified inadequate training and procedures for 111 and ambulance dispatch staff when locating callers with incomplete address details, leading to significant delays. The North East Ambulance Trust's investigation and new protocols were deemed insufficient, with no robust policy or specific training implemented eight months after the death.
Addressed to: North East Ambulance Trust
AI-generated concerns summaryThe coroner noted concerns regarding a lack of communication between Thames Valley Police and Gloucestershire Constabulary, and within Gloucestershire Control, meaning high-risk information about a prior incident was not available to officers conducting a welfare check. This prevented them from initiating a Mental Health Act assessment.
Addressed to: Thames Valley Police; Gloucestershire Constabulary
AI-generated concerns summaryThe coroner noted important patient history, including ESBL E. coli acquisition abroad, was not captured or shared between hospitals, impacting treatment and infection control. Additionally, All Wales Inter Hospital Transfer documentation was incomplete and requires revision.
Addressed to: Welsh Government
AI-generated concerns summaryThe coroner noted concerns that hospital protocols for foeticide before induction of labour do not allow its use at 21/40 gestation, which results in live births following late terminations. This situation is distressing for both staff and parents.
Addressed to: North Devon District Hospital
AI-generated concerns summaryThe coroner noted insufficient provision of psychiatric counselling advice for vulnerable witnesses and timely explanations to complainants about criminal trial directions. Additionally, measures are needed to secure prescribed medication from family members at overdose risk.
Addressed to: Director of Public Prosecutions; Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inconsistent recording of fall risk levels, delayed implementation of identified risk minimisation measures, and a lack of risk assessment review after subsequent fall incidents.
Addressed to: Dovecote Lodge
AI-generated concerns summaryConcerns include inadequate GP assessment and documentation, a presumption of psychological issues without excluding organic causes, and a lack of systems for managing electrolyte abnormalities such as hyponatraemia. Additionally, referrals to eating disorder services lacked sufficient detail to prompt consideration of organic causes.
Addressed to: East Surrey Clinical Commissioning Group; Eating Disorder Services for Adults; Royal College of Pathologists; Royal College of Physicians; Royal College of Psychiatry; Woodlands Surgery