Browse 6,470 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 after a subdural haematoma was not identified in an initial CT scan report by an out-of-hours service, delaying appropriate treatment. Additionally, blood-thinning medication was administered despite being contraindicated while awaiting further scan results.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a pre-admission bed rail assessment despite the patient's mobility issues and family concerns. There was also a lack of clarity among nursing staff regarding the appropriate timeframe and procedure for conducting bed rail assessments at the care home.
Addressed to: Care UK
AI-generated concerns summaryThe coroner noted issues with an Emergency Power Off (EPO) circuit activation, identifying staff lacked local control. Concerns included no in-lab indicator and insufficient guidance on remote control placement, causing critical delays.
Addressed to: HSE; NHS England
AI-generated concerns summaryThe coroner noted unexplained injuries, deficient record-keeping, and delayed medical advice following an unwitnessed fall at Eastcroft Nursing Home. Concerns were raised regarding an ongoing risk to current residents.
Addressed to: Eastcroft Nursing Home
AI-generated concerns summaryCritical clinical information regarding renal findings was not available to spinal surgeons before spinal surgery, leading to issues with treatment prioritization. The Trust did not formally investigate this incident or consider learning points for several months.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of training for midwives on recognising foetal compromise and escalating emergencies, alongside insufficient policies for additional staffing. Concerns were also raised regarding inter-professional communication and the culture of professional challenge within the maternity unit.
Addressed to: Musgrove Park Hospital
AI-generated concerns summaryThe coroner noted concerns regarding a paramedic's interpretation of a ReSPECT form, where it was understood that resuscitation should not be attempted for choking, even if reversible. This approach was identified as potentially inconsistent with the form's intended application.
Addressed to: Beccles Medical Centre
AI-generated concerns summaryThe coroner noted concerns regarding the unregulated online sale of lithium-ion batteries for e-bike conversions and the disclaimed responsibility of online marketplaces for third-party goods. The report also highlights a need to increase public awareness of the fire risks associated with these batteries in domestic properties.
Addressed to: Office for Product Safety and Standards
AI-generated concerns summaryThe coroner noted patients in the Emergency Department were treated in corridors due to capacity issues, despite this area not being designated as clinical. This practice remains ongoing, with no clear timeline for its cessation.
Addressed to: Department of Health and Social Care; NHS England; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that staff at The Meadows Nursing Home did not consistently provide assistance with Mr. Sparrow's food and fluid intake, and that care notes contained false entries. This raised concerns about the accuracy of record-keeping and the thoroughness of internal investigations.
Addressed to: Cardinal Health
AI-generated concerns summaryThe coroner noted a lack of communication protocols between Network Rail signallers and the train company's incident management, which meant the attending Driver Manager was unaware of a driver's distress call. This gap in information sharing hindered the assessment of the driver's welfare.
Addressed to: Network Rail
AI-generated concerns summaryThe coroner identified gaps in recording and communicating a patient's injury, resulting in inappropriate care and delayed medical attention. There were also instances of healthcare assistants not following the care plan.
Addressed to: Belle Green Court Care Home
AI-generated concerns summaryRoyal College Guidance for reporting images from external organisations to NHS Trusts is not understood or embedded, and ambulance response times were significantly delayed due to high escalation levels and hospital handover issues.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a lack of regard for the mother's knowledge of her pregnancy and estimated due date, and an absence of discussions with parents regarding possible measures for premature labour before 22 weeks.
Addressed to: Sheffield Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryMental health services did not make attempts to speak to Mark directly to properly and adequately assess his mental health condition.
Addressed to: South West Yorkshire Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inadequate application of police restraint training, including prolonged prone positioning and extreme arm placement. Concerns were also raised about ineffective welfare monitoring, a failure to apply the National Decision Model, and officers not challenging inappropriate restraint techniques.
Addressed to: Central North West London NHS Foundation Trust; Milton Keynes University Hospital; Thames Valley Police
AI-generated concerns summaryThe report identifies concerns that an unqualified manager admitted a resident with a history of physical aggression, and staff felt unable to question this decision. Additionally, inadequate risk assessments and care plans were noted, suggesting insufficient staff training.
Addressed to: Capital Care Group
AI-generated concerns summaryThe coroner notes repeated adverse incidents regarding patient allergy status checks, despite internal communications and audits. There is concern that the Trust lacks a robust, embedded policy detailing how allergy status must be consistently checked and documented, posing a continued risk to patient safety.
Addressed to: Royal Wolverhampton NHS Trust
AI-generated concerns summaryEmergency Departments do not have reliable access to patients' primary care records, including recent GP consultations, which can delay diagnosis and undermine patient safety.
Addressed to: Bedford General Hospital; Luton and Dunstable Hospital; Milton Keynes University Hospital; Stoke Mandeville Hospital
AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, which creates a demand for replacement drugs.
Addressed to: Boomtown Festival; Hampshire and IOW Constabulary