Browse 6,470 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 summaryPoor documentation, communication, and systems meant urgent tests were not undertaken due to inaccurate medical records. The report also identified that tests could be cancelled by unidentified staff without rationale or accountability.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryThe report identifies an issue with discharging individuals who quickly appear well after recent self-harm or suicidal thoughts, noting that a psychiatrist did not review them before discharge and a senior psychiatric nurse made the decision.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner highlighted that ambulance response times were adversely affected by significant delays in clearing ambulances at hospital Emergency Departments. This was exacerbated by high service demand, challenges in primary care access, and extended turnaround times at hospitals impacting vehicle availability.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryLimited legal powers and resources for mental health patients in Emergency Departments, coupled with a severe shortage of mental health facility beds, result in vulnerable patients remaining in ED for extended periods.
Addressed to: Deputy Director of Patient Safety NHS England; Health Services Safety Investigations Body (HSSIB); National Director FOR Mental Health; NHS England Improvement (PFDs)
AI-generated concerns summaryInadequate fluid management and nursing assessments failing to identify deteriorating patients on wards were identified. A risk of no clinical assessment in the Emergency Department prior to mental health referral or discharge was also noted.
Addressed to: Chief Executive, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient communication and public awareness regarding the fire risks associated with emollient creams, especially near heat sources. There is also a discrepancy in recorded deaths between fire services and the MHRA, indicating a need for a more robust data reporting system.
Addressed to: National Fire Chiefs Council
AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.
Addressed to: South-East London Integrated Care System; Chief Nursing Officer, NHS North-East London Integrated Care Board; South East London ICB; National Medical Director, NHS England
AI-generated concerns summaryAn MHRA drug safety alert regarding nitrofurantoin's pulmonary risks did not appear on the prescribing system because it only triggers for pre-existing conditions. Awareness of potential pulmonary damage from nitrofurantoin in the elderly may also be low among GPs and hospital clinicians.
Addressed to: EMIS Health; Medicines and Healthcare Products Regulatory Agency (MHRA)
AI-generated concerns summaryThe coroner notes the risk of fatal cardiac side effects from Elvanse, the potential for patients with ADHD to forget verbal advice, and concerns about relying on patient-provided data during remote consultations for monitoring.
Addressed to: Minister for Health and Social Care; President of the Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted delays in Ms Pham receiving a post-partum smear test due to strict application of National Cervical Screening Guidance and staff shortages. Concerns were raised that this guidance might disadvantage post-partum women in identifying cervical cancer symptoms.
Addressed to: National Institute for Health and Care Excellence; NHS England; NHS Improvement - NHS Cervical Screening Programme (NHS CSP)
AI-generated concerns summaryThe coroner noted inadequate mental health monitoring, unaddressed subtherapeutic medication levels, and poor communication within the mental health team, alongside concerns about the lack of fall prevention mitigation on the car park's penultimate floor.
Addressed to: Basildon Car Park Management; Essex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the deceased received incorrect medication upon discharge and missed antibiotic doses due to stock issues that were not escalated. There was a lack of clarity on the cause of these medication errors and systems to prevent future occurrences.
Addressed to: UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
AI-generated concerns summaryThe coroner identified concerns regarding the safety of a non-signalised crossroads junction, noting its inherent confusion around priority and a history of at least 27 road traffic incidents. Additional measures could be considered to mitigate safety risks.
Addressed to: Birmingham City Council
AI-generated concerns summaryConcerns were raised regarding the absence of a clearly defined pathway for young people transitioning from CAMHS to adult mental health services, and a lack of clear guidelines for depot antipsychotic administration. Staff also showed uncertainty about s117 Mental Health Act aftercare.
Addressed to: Department of Health and Social Care; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted the absence of documented rationale or further SALT assessment before a patient was removed from a soft food diet. Additionally, food brought in by the patient's husband was not checked for suitability by care home staff.
Addressed to: Oak Tree Mews Care Home
AI-generated concerns summaryThe coroner noted custody sergeants' insufficient understanding of Liaison and Diversion team processes, including information access and pre-release risk assessments. There was also a noted training need for staff regarding support for vulnerable individuals at discharge.
Addressed to: South Yorkshire Police
AI-generated concerns summaryAn error led to a reduction in care round frequency from hourly to four-hourly, and the cause of this error remains unknown, raising concerns about its potential recurrence and future impact.
Addressed to: County Durham & Darlington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that policies and templates for managing patient leave and off-ward safety were unaligned, leading to insufficient prominence for safety planning for voluntary patients going off the ward.
Addressed to: South West London and St Georges Mental Health NHS Trust
AI-generated concerns summaryThe coroner raises concerns about the lack of psychiatric beds in Surrey, leading to patients needing Mental Health Act admission being detained in an unsuitable emergency department environment without legal safeguards or appropriate mental health care.
Addressed to: Department of Health and Social Care; Epsom General Hospital; Health and Care Professionals Council; Health Services Safety Investigations Board; South East Coast Ambulance Service; South West London Integrated Care Board; Surrey and Borders NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about delays in the national rollout of 24/7 crisis text services, which results in reliance on charities with varying policies for immediate risk, leading to inconsistent support and coordination gaps.
Addressed to: Department of Health and Social Care; Greater Manchester Integrated Care Board; NHS England