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 the absence of a Root Cause Analysis investigation, a lack of input from senior clinical staff at the time of presentation, and an unacceptable delay between readmission and arrival in theatre.
Addressed to: Southend Hospital
AI-generated concerns summaryThe coroner identified concerns about previously unknown 'blind spots' in hospital bleeper systems that could delay emergency responses, and the absence of a policy for prompt transfer of Cerebral Venous Sinus Thrombosis patients to regional neuroscience centres for specialised treatment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted removable bathroom rails created ligature points, staff were unaware they were removable, and an undetected blade was brought onto the ward. Concerns were also raised about fragmented communication preventing an overall view of the patient's escalating condition and the incomplete dissemination of assessments.
Addressed to: Care Quality Commission; Cumbria Clinical Commissioning Group; Cumbria Partnerships NHS Foundation Trust; Department of Health and Social Care; NHS England
AI-generated concerns summaryIndependent expert testing found that the combined use of a specific tracheostomy tube and a particular Velcro strap compromised the tube's integrity, likely causing its detachment. The coroner also raised concerns about the broader implications for continued use of Velcro strap attachments with tracheostomy tubes.
Addressed to: Department of Health and Social Care; Surrey Community Health
AI-generated concerns summaryThe coroner raised concerns about the ongoing danger of looped blind cords to young children, emphasising the risk posed by millions of blinds already installed in homes. There is a need for extended public awareness campaigns for parents, grandparents, and carers.
Addressed to: Department for Business Innovation and Skills
AI-generated concerns summaryConcerns included missing medical records, inconsistent falls risk assessments, and an inactive fall alarm during a patient's fall. The coroner also identified difficulties with inter-hospital patient transfers and incompatible electronic and paper patient record systems.
Addressed to: Central Manchester University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that out-of-hours doctors do not have access to the "Allergies" section of patient medical notes, hindering their ability to verify medication appropriateness, especially when patients provide incorrect information or lack capacity.
Addressed to: Beacon Healthcare; Isle of Wight Clinical Commissioning Group
AI-generated concerns summaryThe Fire Diary's wording for fire risk assessment reviews did not prioritise them before changes in use or structure. Junior Fire NCOs also lacked specific training to identify significant electrical overloading in appliances.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner identified that the Fire Risk Assessment document's wording should be revised to prioritise review before changes in use or structural alterations. Further, the report describes a need to confirm the sufficiency of training for Junior Fire NCOs to recognise complex electrical overloading issues.
Addressed to: Ministry of Defence
AI-generated concerns summaryMissing hospital documentation, including patient observations, was noted to jeopardise post-death investigations. Concerns were also raised about delays in transfer to a High Dependency Unit and in treatment due to bed and staffing shortages after the holiday period.
Addressed to: Arrowe Park Hospital
AI-generated concerns summaryThe coroner identified a need for improved training for force control operators on police pursuit policies and responsibilities. Concerns were also raised regarding the lack of an efficient notification system for pursuits and insufficient staffing on the 'Force desk'.
Addressed to: Surrey Police
AI-generated concerns summaryThe coroner noted inadequate record-keeping practices at St Richards Hospital regarding the recording and prescription of oxygen levels, and issues with the application or deviation from the NEWS system.
Addressed to: Western Sussex Hospitals NHS Trust
AI-generated concerns summaryThe hospital's literature provided to new mothers about the dangers of co-sleeping is available only in the English language.
Addressed to: Luton and Dunstable University Hospital
AI-generated concerns summaryThe coroner noted that the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed.
Addressed to: Luton and Dunstable University Hospital
AI-generated concerns summaryThe coroner noted a doctor lacked required ACCT training and concerns were raised about the subjective wording of ACCT trigger events, which led to inconsistent officer assessments due to insufficient detail in records. There was also a lack of clarity on how to obtain community mental health records.
Addressed to: HMP Swansea; MINISTRY OF JUSTICE; National Offender Management Service
AI-generated concerns summaryThe coroner noted ongoing differences in professional opinion regarding the appropriate steps to prevent similar incidents, acknowledging that resolving these differences was beyond the inquest's scope.
Addressed to: Terex Global Gmbh
AI-generated concerns summaryThe crisis team did not follow up with police after requesting a welfare check when police did not call back, and there was no clear protocol for such situations.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe Trust's process for appointment follow-up lacked family involvement and communication. Additionally, the development of a partnership with Greater Manchester Fire and Rescue Service to share information for home safety checks for vulnerable individuals was hindered.
Addressed to: 5 Boroughs Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a discrepancy between audit findings and the actual availability of trained lifeguards and resuscitation equipment at a holiday resort. Concerns were also raised that audit questions regarding lifeguard supervision and first aid training were not mandatory requirements within industry best practice guidelines.
Addressed to: Federation of British Tour Operators
AI-generated concerns summaryThe coroner noted a lack of knowledge and understanding between involved agencies, alongside inadequate communication. Individual Management Reviews (IMRs) were kept confidential and not shared, preventing agencies from commenting on areas of mutual concern.
Addressed to: Worcestershire Safeguarding Children’s Board