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 raised concerns about the slow electronic transfer of echocardiograph studies to tertiary centres and the workload pressures experienced by specialist paediatric retrieval teams.
Addressed to: Congenital Heart Services Clinical Reference Group; Coronary Heart Disease Review; Coronary Heart Disease Review’s Clinical Advisory Panel; East Anglia Team
AI-generated concerns summaryThe coroner identified gaps in gathering medical history, managing complex medications, documenting test results, and assessing detainees' fitness for transfer, including ensuring sufficient notice for these assessments prior to transfer to court.
Addressed to: Ministry of Justice; NHS England
AI-generated concerns summaryThe coroner noted insufficient clinical information in imaging requests, leading to rejections and a lack of context for radiologists. Concerns were also raised about the robustness of post-untoward incident investigations in establishing facts and identifying lessons learned.
Addressed to: West Suffolk Hospital
AI-generated concerns summaryConcerns involved delayed patient transfer and staff's non-recognition of constant observation status due to inadequate handover, alongside the return of a ligature risk belt. The report also noted an ineffective sloping door designed to prevent hanging and reduced staff risk awareness on the ward.
Addressed to: South Stafford and Shropshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the absence of specific qualifications for pressure testing gas pipelines and the lack of a national requirement for gas industry operatives to undergo retraining and re-testing.
Addressed to: Department of Business, Innovations and Skills; Energy and Utilities Skills
AI-generated concerns summaryThe coroner noted concerns regarding procedures for transferring patients between mental health trusts, specifically that a referral for a patient with complex needs was sent via a GP and not received until after the patient's death, rather than directly between trusts.
Addressed to: Coventry and Warwickshire Partnership NHS Trust
AI-generated concerns summaryConcerns included the GP practice's failure to recognise the severity of ulceration and the District Nursing service's inadequate treatment of necrotic ulcers. A lack of organised transport also prevented the patient from attending necessary hospital appointments.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust; North Shore Surgery
AI-generated concerns summaryThe coroner noted concerns that extensive bruising sustained by Mrs Care during her hospital stay, which contributed to her death, could not be explained. There was no evidence to determine how the trauma occurred, despite speculation about hoist use.
Addressed to: Royal Cornwall Hospital Truro
Addressed to: HMP Pentonville
AI-generated concerns summaryThe coroner raised concerns regarding the Health Board's ability to balance a patient's right to confidentiality with the potential benefits of facilitating familial support to optimize recovery.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted a lack of mandatory or regular refresher training for GPs at a national level regarding the prescription of specific pain relief medications, which could lead to fatal errors.
Addressed to: Royal College of General Practitioners
AI-generated concerns summaryThe coroner raised concerns about a patient experiencing a morphine overdose despite receiving less than the maximum prescribed dose. Attention was drawn to whether recommended maximum doses should consider factors like body weight, co-morbidities, and potential drug buildup in the body for long-term therapy.
Addressed to: National Institute for Health and Clinical Excellence
AI-generated concerns summaryConcerns were raised about window restraints appearing secure but being easily defeated, and the lack of a system for CQC inspectors to be fully aware of Department of Health alerts regarding these devices.
Addressed to: Care Quality Commission; Department of Health and Social Care
AI-generated concerns summaryThe DNA CPR form lacked the issuing consultant's hospital and contact details, and its validity wording was unclear, leading to misinterpretation. There is no clear process for retrieving and marking expired or invalid forms.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted that a specific drug and some of its chemical compounds were not controlled by legislation at the time of death, with only a partial temporary ban enacted for some compounds later.
Addressed to: The Advisory Council on the Misuse of Drugs
AI-generated concerns summaryThe coroner identified risks associated with greatly reduced visibility on the M5 motorway due to a nearby firework display, and the absence of automatic signalling to detect speed reductions and warn approaching drivers.
Addressed to: Department for Transport; Directorate for Business Innovation and Skills; Directorate South West; Health and Safety Executive; Directorate South West
AI-generated concerns summaryThe coroner noted inadequate record-keeping and unclear processes for prescribing medication within the GP practice. Concerns were also raised about the GP's lack of action after being alerted to a patient's extreme risk and difficulty managing their diabetes.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of formal assessment for a frail, elderly patient's abilities, home environment, or post-discharge needs before early morning discharge. The department also lacked a formal policy for risk-assessing such discharges.
Addressed to: Chesterfield Royal Hospital
AI-generated concerns summaryThe coroner noted concerns regarding a wind tunnel effect, created by open front and back doors of the Public House, which caused the back door to move suddenly and forcibly, resulting in an accident.
Addressed to: Stockton Public House
AI-generated concerns summaryThe withdrawal of a coloured wrist band system for identifying elderly patients at risk of falls, without replacement, removed a layer of protection and may increase the risk of future falls and deaths.
Addressed to: Arrow Park Hospital NHS Trust