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 raised concerns about the policy of dispensing several days' supply of methadone to drug-dependent individuals during public holidays, noting the risk of future deaths when usual provision methods are suspended.
Addressed to: Bromley Drug and Alcohol Service; United Pharmacy
AI-generated concerns summaryThe coroner noted concerns regarding pedestrian safety at a busy intersection where people frequently cross against flashing lights, and bus visibility is impacted by the bus stop's location, requiring buses to cross three lanes quickly.
Addressed to: London Borough of Camden
AI-generated concerns summaryMrs Poore's depression deteriorated after she started antidepressant medication, and her death was not prevented despite the medication carrying a warning of this potential side-effect.
Addressed to: NHS England
AI-generated concerns summaryThe coroner notes that hourly night observations did not routinely check if patients had moved or remained immobile, and there was a lack of continuity in staff undertaking observations.
Addressed to: Norvic Clinic
AI-generated concerns summaryThe coroner identified concerns regarding the maintenance of accurate and updated medical records, specifically relating to medication details. There was also a lack of an effective system for issuing repeat prescriptions and reviewing patients according to guidelines.
Addressed to: Horsham and Mid Sussex Clinical Commissioning Group; Royal College of General Practitioners
AI-generated concerns summaryNorth West Ambulance Service personnel are not trained in control and restraint techniques, leading to calls for police assistance with unwell patients. This can result in clinically unwell patients being handled by non-clinically trained police and delays in hospital transport.
Addressed to: Department of Health and Social Care; North West Ambulance Service
AI-generated concerns summaryConcerns were raised regarding the delay in obtaining and sharing details of Mrs Walker's previous diabetes medication and acceptable blood test results. Her medical condition and blood test readings were not appropriately recorded in clinical notes, and an available defibrillator was not applied before ambulance personnel arrived.
Addressed to: 5 Boroughs Partnership
AI-generated concerns summaryThe coroner noted concerns regarding the A444, where pedestrians and cyclists frequently use the carriageway verge, yet there are no warning signs, street lights, or protective barriers despite a 70mph speed limit. This situation poses a risk of further fatal collisions.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe coroner identified a lack of effective supervision for paediatricians, particularly during out-of-hours, and insufficient independent consultant assessment for paediatric admissions. Concerns also included the ineffective application of national guidelines for fever in children under one year and a failure to act on a parent's concerns.
Addressed to: Department of Health and Social Care; Frimley Park Hospital; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Addressed to: Frimley Park Hospital NHS Trust; North East Hampshire and Farnham Clinical Commissioning Group; Royal College of Surgeons
AI-generated concerns summaryThe coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Addressed to: Surrey and Sussex NHS Trust
AI-generated concerns summaryThe coroner raised concerns that care home visits were not standard practice before placing individuals with complex needs, relying instead on the home's assurances. There was also uncertainty regarding guidelines or protocols for undertaking such visits during the assessment and placement process.
Addressed to: Cambridgeshire County Council
AI-generated concerns summaryThe coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
Addressed to: Queens Hospital Burton Upon Trent
AI-generated concerns summaryThe coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Addressed to: West Wales General Hospital Glangwili Carmarthen
AI-generated concerns summaryThe defibrillator machine was inoperable and had not been checked daily as required. There was no cross-check system or policy for the management of sudden unexpected deaths in place at the hospital.
Addressed to: St Mary’s Hospital Warrington
AI-generated concerns summaryThe coroner identified issues with the GP's clinical management of the patient's mental health, including the absence of specialist referral and lack of recognised assessment tools. Concerns were also raised about bureaucratic barriers preventing GPs from easily accessing mental health services.
Addressed to: Department of Health and Social Care; Pennine Care NHS Trust; Rochdale Heywood and Middleton Clinical Commissioning Group; York House Surgery
AI-generated concerns summaryThe coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Addressed to: Arrowe Park Hospital
AI-generated concerns summaryThe coroner noted that the crossing point in Westhead Avenue, marked by tactile paving, is likely too close to Weston Road, suggesting an extension of protective railings and moving the crossing further into Westhead Avenue.
Addressed to: Casualty Reduction Team
AI-generated concerns summaryThe coroner raised concerns regarding a specific road section where a collision occurred, recommending a review of the location for the appropriateness of warning signs or road markings.
Addressed to: Casualty Reduction Team
AI-generated concerns summaryThe coroner raises concerns regarding the appropriate and justifiable use of tasers by firearms officers, noting discrepancies in the account of events immediately preceding the tasering.
Addressed to: West Yorkshire Police Force