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 insufficient communication between the hospital, social services, and the family regarding the patient's discharge plan. Concerns were also raised about the patient being discharged home with severe pressure sores and no pressure-relieving mattress.
Addressed to: Tameside Metropolitan Borough Council; Tameside NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient information regarding the caffeine content and dangers of consuming large quantities of 'Hero Energy Mints.' The product's ambiguous classification between medication and sweets raised concerns about consumers potentially mistaking it for ordinary confectionery.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of robust systems for tracking and reconciling race participant numbers, meaning a missing runner was not identified. Concerns also included insufficient communication between race control and marshals.
Addressed to: Fell Runners Association
AI-generated concerns summaryThe coroner identified a lack of national guidance for independent medical service providers on how to alert NHS hospitals about incoming urgent patients. This absence causes confusion and poses a risk to critically ill individuals arriving at hospitals without prior notification or preparation.
Addressed to: Department of Health and Social Care; Manchester Medical Service; North West Ambulance Service; Salford Royal Hospital NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding hotel security leaving the deceased unattended on a landing for six hours without subsequent checks. He was rediscovered by a guest the next day, not a staff member, despite staff awareness of his presence.
Addressed to: Jurys Inn Birmingham
AI-generated concerns summaryThe coroner identified a lack of medical supervision for inpatients and inadequate systems for managing acutely ill elderly patients with complex conditions. There were also concerns about an insufficient understanding of legal duties under the Mental Health Act 1983 and Mental Capacity Act 2005 during patient transfers.
Addressed to: Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in implementing a new door security system for secure wards, insufficient staffing levels on a ward, and the unavailability of a patient's photograph for police during a disappearance.
Addressed to: Sheffield Trust
AI-generated concerns summaryThe coroner noted concerns regarding the policing of internal pharmacy error records and the lack of mandatory read-back procedures or software to prevent dispensing mistakes. There is also no central database for monitoring prescription errors.
Addressed to: Department of Health and Social Care; General Pharmaceutical Council; NHS England; Royal Pharmaceutical Society of Great Britain
AI-generated concerns summaryThe coroner noted a lack of transport heater availability, which could lead to patients becoming hypothermic during transfer and potentially result in death.
Addressed to: University College London Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted unadopted recommendations from a 2011 report on carbon monoxide deaths and insufficient guidance on CO movement within buildings. Further concerns related to the Fire and Rescue Services' lack of a statutory role in CO safety and a need for regulators and fuel suppliers to review preventative actions.
Addressed to: All Party Parliamentary Gas Safety Group; Association of Chief Fire Officers; Department for Energy and Climate Change; Greater Manchester Fire and Rescue Service; GS Halls Limited; Health and Safety Executive; Ministry of Communities and Local Government; National Grid; Ofgem
AI-generated concerns summaryThe coroner identified concerns regarding the absence of an agreed protocol for managing calf pain and suspected DVT at the Urgent Care Centre. Additionally, questions were raised about a specific GP's understanding and acceptance of normative diagnostic standards and the adequacy of practice changes.
Addressed to: Bromley Healthcare; Cator Medical Centre; Beckenham Beacons UCC; General Medical Council; NHS Bromley Clinical Commissioning Group
AI-generated concerns summaryThe coroner noted that staff did not escalate Mrs Jones' care and failed to communicate all relevant information to healthcare professionals, which led to uninformed decisions and an inappropriate care package.
Addressed to: Manor Residential and Nursing Care Home
AI-generated concerns summaryThe coroner identified a lack of an efficient system for the speedy reassessment and transfer of patients whose condition is rapidly deteriorating, leading to delays in moving individuals to suitable alternative accommodation.
Addressed to: Bromleys Solicitors; Care Quality Commission; Fentons Solicitors; Manchester Clinical Commissioning Group; Mayfield Care Home; Trafford Borough Council
AI-generated concerns summaryThe coroner identified a lack of communication between the hospital and home regarding mental capacity assessments, and unqualified medical carers evaluating patient capacity. Concerns were also raised about poor note-taking and continuity of patient care records.
Addressed to: Surrey County Council
AI-generated concerns summaryThe coroner noted that Mr. Anderson's GP was not informed of his hospital admissions, leading to issues with medication supply. Furthermore, after an early discharge, there was over-reliance on family for information, and no care plan was established to assess his needs.
Addressed to: Kent and Medway NHS; Social Care Partnership Trust
AI-generated concerns summaryThe coroner noted delays in acting on an emergency mental health referral and a lack of clear understanding of appropriate team roles. Concerns also included insufficient action on specific suicidal ideation and poor information sharing between mental health professionals.
Addressed to: Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryThe patient's medical notes were altered, removing a documented penicillin allergy without signature or verification, which led to a penicillin-containing antibiotic being prescribed and posed a risk of anaphylactic shock.
Addressed to: Queen’s Hospital
AI-generated concerns summaryThe coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
Addressed to: University Hospital Coventry and Warwickshire
AI-generated concerns summaryThe coroner identified ineffective communication among hospital staff, a failure to diagnose a fracture in the Emergency Department leading to delayed treatment, and the patient remaining on an orthopaedic ward when a medical team transfer was needed.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted failure to escalate care despite a marked increase in the Early Warning Score (SHEWS) and miscalculations. Concerns included the absence of a national, standardised Early Warning Score system and automatic alerts for deteriorating patients.
Addressed to: Department of Health and Social Care