Browse 6,458 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 gaps in the NHS 111 Pathways system, noting the absence of a dedicated category for neurosurgery patients and that call handlers did not ask about post-surgical 'red flag' discharge advice.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified issues with the driveway's safety, including the absence of a protective barrier at a sheer drop and a lack of clear procedures for managing icy conditions. Concerns were also raised regarding the absence of instructions for safe vehicle unloading to prevent run-away incidents.
Addressed to: Howarth Properties LTD
AI-generated concerns summaryThe coroner noted insufficient early specialist centre involvement and patient consultation for a complex procedure. Concerns were also raised about William Harvey Hospital's systems for tracking critical test results and ensuring referral completion.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryCare and behavioural support plans for a resident with escalating aggressive behaviour were not updated, reflecting staff's lack of understanding and management's absence of a system for updates. The internal investigation also did not identify these plan deficiencies.
Addressed to: Adept Care Homes
AI-generated concerns summaryThe coroner raises concerns that the monitor manufacturer has not yet made a decision regarding the hospital's request to lock or default alarm volumes to maximum, which could enhance patient safety.
Addressed to: Masimo UK
AI-generated concerns summaryThe SystmOne electronic patient record system can deactivate a patient's active record when a previous organisation accesses it, removing current care plans and risking unsafe clinical care. A national technological solution is preferable.
Addressed to: NHS England
AI-generated concerns summaryConcerns include the GP surgery's lack of follow-up and consideration of specialist mental health referral for deteriorating mental health. The coroner noted medication was prescribed without psychiatrist input, and there was a 15-week delay in adjusting the patient's medication.
Addressed to: Foxhayes Surgery GP Practice
AI-generated concerns summaryThe coroner notes a lack of mandatory refresher first aid and CPR training for prison staff. Additionally, there are issues with delays in prisoners receiving essential medications prescribed on FP10 forms outside of hours, and an absence of a clear policy for managing such prescriptions.
Addressed to: DHSC; HMPPS; HMP The Verne; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner identified poor documentation and insufficient managerial oversight within the District Nursing team, leading to a lack of prompt escalation for deteriorating conditions. Additionally, the GP practice lacked an effective system for promptly triaging referrals from the 111 service or family information.
Addressed to: Tameside NHS Foundation Trust; Brooke Surgery
AI-generated concerns summaryThe report identifies insufficient awareness and training within ambulance services and careline companies for using careline systems for direct communication and handling third-party emergency calls. Critical information was also not fully relayed.
Addressed to: Appello Careline Operations Director; Association of Ambulance Chief Executives; NHS England; South East Coast Ambulance Service NHS Foundation Trust; Telecare Services Association
AI-generated concerns summaryThe coroner identified gaps in formal adult safeguarding reviews and dedicated transition teams for young people approaching adulthood. Concerns also highlight the need for national standardisation in policing child sexual exploitation and guidance for missing persons.
Addressed to: Department for Education; Home Office; National Police Chief’s Council
AI-generated concerns summaryThe coroner noted a lack of national guidance and timelines for administering medication in mental health crises, which contributed to a significant delay in Jake receiving Diazepam. Additionally, Mental Health Liaison Team prescribers at the hospital lacked direct access to medication, causing further delays.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner notes that NHS Pathways advises callers an ambulance is being arranged, but for lower priority calls, dispatch is delayed by clinical validation without informing the caller. Additionally, callers cannot be advised of estimated waiting times for an ambulance.
Addressed to: NHS England & NHS Improvement; South East Coast Ambulance Service NHS Foundation Trust
AI-generated concerns summaryDelays in commencing critical medication stemmed from a lack of communication and follow-up on abnormal blood test results, which were not reviewed despite clinical deterioration. Concerns were also raised about unclear responsibility for ongoing patient care between departments.
Addressed to: Rotherham District General Hospital
AI-generated concerns summaryThe coroner identified issues with unclear procedures, training, and operator information for handling quick-succession sprinkler system signals, potentially affecting emergency calls. There was also no evidence of regular system testing or maintenance.
Addressed to: Birmingham City Council
AI-generated concerns summaryThe coroner noted a lack of guidance for GPs on prior cancer as a red flag for specialist referral without further tests. Waiting times for specialist evaluation in these circumstances are between six to twelve months.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of a clear pathway for specialist interpretation of abnormal ECG traces by paramedics who do not convey patients to hospital. Concerns were also raised that patients with intermittent chest pain, breathlessness, and abnormal ECGs were not taken to hospital and not advised to show the …
Addressed to: London Ambulance Service; NHS England
AI-generated concerns summaryThe coroner identified a lack of a designated lead or single point of contact for young people with complex health and drug issues, leading to fragmented information sharing among agencies. There is also an absence of a national mechanism to highlight significant historical health and drug misuse risks across patient …
Addressed to: Department of Helath and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a lack of out-of-hours consultant radiologist cover for hospitals in Exeter, Plymouth, and Torbay, which is needed for urgent interpretation of complex scans and puts patients at risk.
Addressed to: Isles of Scilly Integrated Care Boards; NHS Cornwall; NHS Devon
AI-generated concerns summaryOut-of-Hours/111 Doctors are blocked from directly booking urgent face-to-face appointments with a patient’s own GP, leading to delays in accessing appropriate care and diagnosis.
Addressed to: PHL Group (Partnering Health Limited)