Browse 6,493 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted the limited availability of psychological therapy at Avesbury House, raising concerns about potential adverse consequences for patients discharged into the community after discontinuing therapy.
Addressed to: Barnet Enfield and Haringey Mental Health NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the appropriate deployment of agency nurses in demanding roles, the quality and accuracy of nursing handovers, and the recording of critical medical information in nursing records.
Addressed to: Royal Cornwall Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the road layout at a junction, noting that lanes merge within a very short distance with an acute angle, leading to a delayed line of sight for drivers due due to proximity to another traffic flow.
Addressed to: Leicester City Council
AI-generated concerns summaryThe coroner raised concerns about the design of Optare "hopper" buses, where the lack of seat restraints contributed to an elderly passenger's fatal injury. The report suggests the vehicle's type-approval process gives insufficient weight to serious injury risks.
Addressed to: Optare; Transport Research Laboratory; Vehicle Operator Services Agency
AI-generated concerns summaryInsufficient staffing levels led to staff feeling overwhelmed and unable to escalate care. Many staff were also unaware that an un-recordable blood pressure is a medical emergency requiring immediate resuscitation, suggesting a need to review crash team protocols.
Addressed to: Luton and Dunstable University Hospital
AI-generated concerns summaryThe coroner raised concerns regarding the lack of a timely medication review for a patient with known addiction issues, and the absence of a detailed record of the medication discussion or a future plan for its reduction.
Addressed to: Roundwell Medical Centre
AI-generated concerns summaryThe coroner noted that the prison service and healthcare did not assess Mr. Scarlett's risk of taking his own life, as staff lacked access to a risk assessment tool or protocol.
Addressed to: National Offender Management Service
AI-generated concerns summaryThe coroner noted insufficient funding and under-resourcing of the Home Treatment Team and Liaison Psychiatry, which affected continuity of care, accurate patient assessments, and the availability of qualified staff for section recommendations. Gaps were also identified in recording pertinent information and providing interim patient support.
Addressed to: Clinical Commissioning Group for Wandsworth; South Wet London and St George’s Mental Health NHS Trust
AI-generated concerns summaryConcerns were raised regarding insufficient A&E department cover for emergency surgical tracheotomy and inadequate training for clinicians in this procedure, impacting their skills and confidence.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified that the junction design at Vernon Place/Southampton Row leaves cyclists vulnerable, with no additional space in the bus lane. There has been slow progress on planned safety improvements for this junction, despite prior cyclist fatalities.
Addressed to: Camden Council
AI-generated concerns summaryThe Salford Royal Hospital lacked a protocol for perioperative management of heart transplant patients undergoing non-cardiac surgery. Additionally, Isoprenaline, an effective anti-bradycardic agent, was not available at the hospital during resuscitation attempts.
Addressed to: Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe coroner identified that the transfer of patients between community nursing teams, due to moves between care homes, lacked a formal handover document. This meant important non-clinical information, such as the use of an airflow mattress, was not consistently communicated, potentially reducing optimal patient care.
Addressed to: Kent Community Health NHS Trust
AI-generated concerns summaryInconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate systems for assessing and signing off locum consultant surgeons as competent for independent practice, noting that while one hospital had improved, similar risks might exist elsewhere.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding the inappropriate green coding of an emergency overdose call, resulting in a significant delay in ambulance response. Gaps in communication and misleading computer-generated codes were identified as contributing factors.
Addressed to: North West Ambulance Service
AI-generated concerns summaryThe coroner noted psychiatric units struggle to provide physical health care and that deep vein thrombosis (DVT) prophylaxis policies were not consistently applied to patients in these units. The report suggests developing a system for integrated physical and mental health care delivery.
Addressed to: Department of Health and Social Care; Sussex Partnership NHS Trust; Western Sussex Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the damaged and overgrown parapet of the B5307 bridge, which had created a "ramp" that caused a vehicle to become airborne. This condition poses a foreseeable risk of similar accidents occurring if not repaired.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner noted repeated instances of a detained patient absconding from the hospital's smoking area, often while escorted by nursing staff. Concerns were also raised about the patient's ability to leave the ward by following an informal patient.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner noted the need for staff training on what constitutes a reportable incident and for managers to be aware of their duty to report. Concerns were also raised regarding the safety and appropriate strength of door-closers to prevent injury.
Addressed to: Borough Care Limited
AI-generated concerns summaryThe coroner identified high levels of Gabapentin in a diabetic patient, a drug generally not prescribed to diabetics due to severe reaction risks. Concerns were raised as the GP did not explain the rationale for this prescription.
Addressed to: Guy’s Hospital; Princess Street Practice