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 summaryConcerns were raised about the hospital administration of PD medication not following patient regimens, the unavailability of doctors for non-emergency weekend reviews, and the unelucidated cause of a dispensing error involving incorrect medication.
Addressed to: University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the poor visibility of old-style filament wig wag lights at level crossings, especially due to glare, and the slow pace of Network Rail's program to replace these with brighter LED lights.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner noted failures to communicate proteinuria from A&E to the ward and the significance of elevated ESR and CK to the patient, family, or GP. This contributed to a missed opportunity to diagnose and treat a connective tissue disorder.
Addressed to: Kings College Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that protective helmets are not compulsory for motorised bicycles exceeding 15 MPH, noting that the deceased's injuries might have been less severe if headgear was mandatory.
Addressed to: Department for Transport; Royal Society for the Prevention of Accidents
AI-generated concerns summaryThe coroner raised concerns regarding the process for managing an individual's mental health risks, including suicidal ideation, after specific details had been communicated to their GP practice.
Addressed to: Mundesley Medical Centre; NHS North Norfolk Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted unclear advice on precautions for a genetic condition, particularly for travel, and a lack of a clear pathway for sharing information with family members. Additionally, no information leaflets were available for the patient about fatal consequences or for family about risks and options.
Addressed to: General Medical Council; National Institute for Health and Care Excellence; The Chief Coroner
AI-generated concerns summaryThe coroner noted that the steps from the canal bridge leading to Gas Street in Skipton are in a dangerous condition, further compounded by poor lighting in the bridge area.
Addressed to: North West Waterways Canal & River Trust; The Chief Coroner
AI-generated concerns summaryConcerns included the absence of national observation protocols for young people in mental health units and a lack of formal information transfer protocols between healthcare sectors. The coroner also noted inconsistent psychiatric referral decisions in A&E.
Addressed to: Affinity Healthcare Ltd; Central Manchester University Hospitals NHS Foundation Trust; Department of Health and Social Care; Greater Manchester West Mental Health NHS Foundation Trust; Manchester Mental Health and Social Care Trust; Royal College of Psychiatrists
AI-generated concerns summaryConcerns were raised regarding nursing staff's understanding of DNACPR forms and the completeness of information required for them. The report also identified insufficient End of Life Care planning to guide staff in supporting residents to die peacefully and with dignity.
Addressed to: Lifestyle Care PLC
AI-generated concerns summaryThe coroner identified significant delays in urgent psychiatric assessments, particularly out-of-hours, and an insufficient system for mentally ill patients on the Medical Admissions Unit. Concerns were also raised about the Level 3 Investigation Report omitting critical medical issues.
Addressed to: Leeds Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the appropriateness of the 60 mph speed limit on a country lane with bends and limited lighting, noting the collision occurred on a bend with a theoretical maximum speed of 60 mph.
Addressed to: Sandwell Metropolitan Borough Council
AI-generated concerns summaryThe coroner identified a lack of detailed national guidance to assist doctors in making decisions about transferring critically ill patients, particularly concerning the preparation of comprehensive written risk assessments for fitness to travel.
Addressed to: The Faculty of Intensive Care Medicine; Intensive Care Society
AI-generated concerns summaryThe coroner noted that the possibility of a rare drug occurrence is not highlighted to physicians in drug literature or in the BNF entry.
Addressed to: British National Formulary; UCB Pharma
AI-generated concerns summaryThe coroner identified a need for an accelerated pathway for neutropenic sepsis patients to prevent prolonged A&E waits, and noted frequent catheterisation without urologist management. The report also suggested considering a vulnerable patient card to expedite emergency care.
Addressed to: Department of Health and Social Care; Torbay Hospital
AI-generated concerns summaryThe coroner noted a lack of effort to fit a cervical collar despite neurosurgeon instructions, an absence of concern raised by most medical staff, and the unavailability of the prescribed collar in a specialist centre.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryThe coroner noted a second death on the same A46 section within a year and recommended reviewing and reducing the speed limit on the 'Hartley Bends'. Improvements to road signs, carriageway markings, and the provision of rumble strips were also suggested to enhance driver safety.
Addressed to: Highways Agency
AI-generated concerns summaryThe coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
Addressed to: Kings College Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a clear policy to determine candidacy for ITU and contradictory messages between nursing and medical staff regarding this.
Addressed to: University Hospital of South Manchester NHS Foundation Trust
AI-generated concerns summaryA lack of adequate communication between the GP practice and the responsible clinician meant the responsible clinician was unaware of the GP's unilateral titration of a patient's amitriptyline and its prescribed timing.
Addressed to: Central and North West London NHS Foundation Trust; NHS Hillingdon Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted deficiencies in the communication of patient discharge information from the hospital to GPs, particularly for practices outside the immediate area. This issue was highlighted as potentially worsening with the integration of Stafford Hospital into the Trust.
Addressed to: University Hospital of North Staffordshire NHS Trust