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 summaryThe coroner raised concerns about the infrequent communication between the Drug and Alcohol team and the GP, and the lack of routine information exchange between services regarding patient prescriptions.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that the 60 mph speed restriction on a bend was unsafe and increased on approach to a bridge. Warning signs were identified as inadequate given the number of recorded incidents at this location.
Addressed to: Rotherham Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted that a local action plan for complex care pathways, particularly for ventilated patients discharged to the community, has not been shared with other Clinical Commissioning Groups, limiting its potential to prevent similar deaths nationally.
Addressed to: NHS England
AI-generated concerns summaryThe presence of a drainage channel and concrete headwall represents a hazard to road users. A safety barrier should be erected to prevent vehicles leaving the carriageway and impacting the headwall.
Addressed to: Caerphilly County Borough Council
AI-generated concerns summaryThe coroner identified delays in initial documentation, an unreviewed omission of prophylactic Dalteparin, and ineffective communication of a pharmacy query. Concerns were also raised that existing systems and policies may not be robust enough to manage human factors.
Addressed to: City Hospitals Sunderland NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, which was important for assessing the patient's fitness for surgery. This gap in communication could lead to future deaths.
Addressed to: South Tees NHS Trust
AI-generated concerns summaryThe coroner noted concerns about the adequacy of public service signposting and funding routes for adult care, leading to a carer lacking respite support. There were also concerns about delays in processing applications for care packages, creating gaps in essential support for carers.
Addressed to: Swindon Borough Council
AI-generated concerns summaryConcerns were raised regarding persistent vehicle speeding in Crow Lane. The coroner identified a need for physical measures, such as speed bumps, to ensure vehicles adhere to the speed limit and reduce collision risks, including those posed by the trief curb.
Addressed to: London Borough of Havering
AI-generated concerns summaryInadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Addressed to: National Offender Management Service; North Tees and Hartlepool NHS Trust; Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe general practice did not monitor the patient's consumption of controlled drug prescriptions, leading to a significant accumulation of medication. This situation was exacerbated as the care worker administering the drugs did not report medical instructions.
Addressed to: Eltham Park Surgery
AI-generated concerns summaryThe coroner expressed concern about the safety of a residential road after several incidents and two fatalities, noting that requested road calming, parking restrictions, and crossing measures had not been introduced.
Addressed to: Birmingham City Council; West Midlands Police
AI-generated concerns summaryThe coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding long waiting times for mental health assessments in hospital emergency departments, attributed to insufficient liaison psychiatry nurse staffing levels. The key issue identified was the long-term sustainability of adequate staffing after temporary funding for increased resources was set to expire.
Addressed to: NHS Medway Clinical Commissioning Group; NHS Swale Clinical Commissioning Group
AI-generated concerns summaryThe Person Escort Record form lacked a section for prior hospital treatment and had issues with securely attaching warning documents, hindering information transfer to the prison. Furthermore, prison staff did not always review all available risk information, and efforts to find a suitable cellmate were insufficient.
Addressed to: HM Prison Cardiff; Home Office
AI-generated concerns summaryThe coroner noted limited visibility at a blind left-hand bend on Tyersal Lane, where trees and foliage impede sight for vehicles, which could lead to future deaths.
Addressed to: Tyersal Farm
AI-generated concerns summaryThe coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Addressed to: Care Quality Commission; Passmonds Care Home; Rochdale Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted insufficient staff training in resuscitation, sporadic physical observations which ceased prematurely, and the lack of an electrocardiogram despite clinical need. Inconsistent staff handovers and unclear communication policies were also identified.
Addressed to: Partnerships in Care; South London and Maudsley NHS Foundation Trust
AI-generated concerns summaryThe coroner noted repeated failures to perform basic nursing observations, inadequate staffing levels and skill mix on the ward, and a lack of staff discipline. There was also a deliberate falsification of nursing records.
Addressed to: Care Quality Commission; Priory Group
AI-generated concerns summaryThe coroner suggested it would be good practice to supply warfarin home management kits to high-risk patients who have undergone heart surgery and are subsequently on warfarin.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the hospital's Falls Risk Assessment tool was subjective and its utility depended on individual nurse opinion, especially when completed by non-Trust staff. A more objectively assessed tool was identified as necessary.
Addressed to: Tameside Hospital NHS Foundation Trust