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 that fly-grazing is not a criminal offence in England and a police/local authority protocol to address it is not yet in force in Suffolk.
Addressed to: Department for Environment, Food and Rural Affairs; Suffolk Constabulary
AI-generated concerns summaryConcerns were raised regarding the regular assessment of emergency care staff for life support standards, and if paramedics with advanced life support training should be mandated for all Code Red and PPCI transfers. Further issues included training for ECG machines for certain staff, and specific guidance for communicating with relatives.
Addressed to: East of England Ambulance NHS Trust; Messrs Hempsons; Messrs Stewarts Law LLP
AI-generated concerns summaryThe coroner highlighted concerns about the adequacy of paramedic intubation training and the mandatory use, availability, and training for waveform end-tidal carbon dioxide monitors in ambulance services. Separately, the report noted issues with EMAS's dissemination of new guidelines to frontline staff.
Addressed to: Association of Ambulance Chief Executives; East Midlands Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner noted a lack of prompt action in treating a suspected life-threatening condition and insufficient effort to address the reasons behind a patient's apparent non-compliance with vital anti-coagulation medication.
Addressed to: Oak Side Surgery
AI-generated concerns summaryThe coroner identified knowledge gaps among doctors and medical staff regarding referral procedures for mental health assessments and engaging Mental Health Partnership personnel, noting a need for improved training on effective communication pathways.
Addressed to: Great Western Hospital
AI-generated concerns summaryThe coroner noted a lack of skill and knowledge among staff regarding NG tube insertion and storage, alongside delayed responses to consultant instructions and patient deterioration. Deficiencies in communication between staff, poor record-keeping standards, and a need for more nursing/medical staff were also identified.
Addressed to: Alexandra Hospital
AI-generated concerns summaryThe coroner raises concerns that Out of Hours Service doctors and hospital Emergency Departments lack direct access to patients' electronic GP notes, noting this could lead to adverse patient outcomes.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of clear responsibility between the senior nurse mental health practitioner and night staff for monitoring a patient in a state of heightened anxiety and agitation in the Emergency Department, resulting in him leaving the unit unwatched.
Addressed to: Royal Devon and Exeter Hospital NHS Trust
AI-generated concerns summaryNursing staff on the Clinical Decisions Unit did not perform a second set of observations or escalate the need for a surgical review, partly due to high patient workload and unfamiliarity with escalation procedures.
Addressed to: East Kent Hospitals University NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need for improved inter-agency working and clearer communication when police assistance is sought for mental health assessments. This includes reviewing current processes and considering an inter-agency protocol for joint management of assessments where risk is perceived.
Addressed to: Norfolk and Suffolk NHS Foundation Trust; Suffolk Constabulary
AI-generated concerns summaryThe coroner notes limited awareness, even in academic circles, of the risk of positional asphyxia associated with baby slings. There are also concerns that information about this risk has not been widely publicised to parents.
Addressed to: University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in the documentation and application of the leave policy for informal patients, particularly regarding risk assessments and decisions for escorted leave. Critical patient information, including risks associated with her home, was not handed over to the escort.
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted significant flaws in Mr. Watts' hospital discharge procedure, including blank paperwork, a lack of communication with his nursing home and family, and his medical unsuitability for discharge. He returned to the nursing home in a deteriorated state.
Addressed to: Brighton and Sussex University Hospitals Trust; Royal Sussex County Hospital; Princess Royal Hospital
AI-generated concerns summaryThe coroner raised concerns regarding information sharing between Durham Constabulary and the County Council, and suggested a review of the County Council's procedures to ensure a timely and proportionate response to potentially dangerous road conditions.
Addressed to: Durham Constabulary; Durham County Council
AI-generated concerns summaryThe coroner noted that the layout of Middle Road and surrounding hedgerows near the bus stop at Tapnell might be affecting drivers' visibility and road safety.
Addressed to: Hampshire Constabulary; Island Roads; Isle of Wight Council
AI-generated concerns summaryThe coroner noted the patient's INR was not checked despite being on Warfarin and having a fall history. Concerns were also raised about an unreported temperature rise to medical staff and a significant delay in A&E assessment leading to a delayed diagnosis.
Addressed to: Dudley Group NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that paediatric child health training is not mandatory for GPs, with less than 25% of trainees undertaking placements, potentially leading to insufficient skills in assessing and responding to sick children.
Addressed to: Department of Health and Social Care; General Medical Council; Health Education England; Royal College of General Practitioners; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner identified a lack of clear command structure and accountability for incident management, alongside issues with communication protocols and the effective use of electronic mapping tools for resource allocation and deployment.
Addressed to: Independent Police Complaints Commission; Northumbria Police
AI-generated concerns summaryThe coroner identified insufficient awareness among care staff and paramedics regarding the increased bleeding risk for elderly patients on warfarin after a head injury. Concerns were also raised about care home staff not following observation instructions, inadequate record-keeping, and the need for improved training on falls prevention and anticoagulants.
Addressed to: BUPA Care Homes; BUPA UK Provision
AI-generated concerns summaryCoroner notes that farm machinery bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions. This creates a road hazard, especially at night, as the chute lacked required visibility markings.
Addressed to: AGCO Ltd