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 the need for national implementation of guidance for end-of-life care and social care needs in prisons. Concerns were also raised about establishing external specialist support for pain management for prisoners.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner noted the patient, medically fit for discharge, was retained in hospital due to insufficient communication and no home assessment, leading to recumbency and pneumonia. Additionally, there was insufficient evidence for making her 'nil by mouth'.
Addressed to: Stockport NHS Foundation Trust
AI-generated concerns summaryThe coroner noted Mersey Care's informal patient leave policy is outdated, unreviewed since 2007, and inconsistent with current practice. It requires immediate updating to include multidisciplinary consensus, patient vulnerability considerations, and clear documentation.
Addressed to: Mersey Care, NHS Trust
AI-generated concerns summaryThe coroner noted lengthy delays in obtaining cardiology reviews and a lack of surgeon input in theatre booking, contributing to operational delays. Concerns also included an insufficient number of surgeons for laparoscopic cases and a query regarding a change in surgical clips.
Addressed to: Stepping Hill Hospital
AI-generated concerns summaryRequired tests were not performed despite being requested by a clinician, which led to a missed opportunity for diagnosis and treatment.
Addressed to: Betsi Cadwaladr University Hospital Board
AI-generated concerns summaryA patient with an abdominal aortic aneurysm was lost to follow-up, leading to a rupture and death. The coroner noted the absence of a specialist nurse clinic and a dedicated procedure database as factors requiring attention.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Addressed to: Department of Health and Social Care; Epsom and St Helier University Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified gaps in senior clinical review and communication that led to delayed urgent admission and investigation of symptoms. The report also describes insufficient appreciation of the patient's serious condition, delays in specialist referral for surgery, and inconsistent antibiotic therapy.
Addressed to: Consultant Physician and Gastroenterologists; East Cheshire NHS Trust
AI-generated concerns summaryThe coroner notes the potential for 'nil by mouth' signage to be inadvertently altered due to the design of double-sided signs and the lack of clarity regarding the cause of a past alteration, raising a risk of recurrence.
Addressed to: Barts Health NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding the design of thumbwheel controls, noting their layout allowed for inadvertent release of locking pins and the absence of dual controls for this function.
Addressed to: British Industrial Truck Association; HM Principle Specialist Inspector
AI-generated concerns summaryConcerns were raised regarding the lack of consultant supervision for on-call paediatric trainees admitting emergency patients and the absence of independent consultant assessment for paediatric admissions at Worthing Hospital. The report also noted a lack of national guidelines for assessing and investigating headaches in children.
Addressed to: Department of Health and Social Care; Royal College of Paediatrics and Child Health; Western Hospitals NHS Foundation Trust; Worthing Hospital NHS Trust
AI-generated concerns summaryConcerns relate to vulnerable Telecare users in Conwy County lacking standard interlinked smoke alarms, with insufficient interim provisions during a two-year roll-out. The council also did not make the deceased aware of available free home fire safety checks.
Addressed to: Conwy County Council
AI-generated concerns summaryThe coroner raised concerns about the waiting time between discharge from crisis services and the first IAPT appointment, and patients not knowing when their next treatment contact would be. It was suggested that follow-up appointments should be arranged before or upon discharge.
Addressed to: Improving Access to Psychological Therapies; Trafford Crisis Resolution and Home Treatment Team
AI-generated concerns summaryConcerns included insufficient recording and consideration for anti-embolic stockings in the patient's notes, and the absence of prescribed anti-coagulant medication upon discharge.
Addressed to: Aneurin Bevan Health Board
AI-generated concerns summaryThe coroner noted inadequate protection, condition, and maintenance of river safety equipment like life buoys and throwing lines, alongside a lack of warning signs. Concerns were also raised regarding North Yorkshire Police training in river rescue protocols, water safety, and hypothermia first aid, and inter-service communication.
Addressed to: City of York Council; North Yorkshire Fire and Rescue Service; North Yorkshire Police
AI-generated concerns summaryThe coroner notes that General Practitioners lack a national mechanism to report ongoing patient information relevant to firearms license suitability due to confidentiality, potentially impeding crucial decisions for public safety. A pilot scheme has demonstrated the benefit of such information sharing.
Addressed to: Association of Chief Police Officers; British Medical Association; Firearms and Explosive Licensing Working Group; Hampshire Constabulary; Criminal Justices and Victims, House of Commons; Minister of State for Victims and Sentencing; Wiltshire Clinical Commissioning Group; Wiltshire Constabulary
AI-generated concerns summaryThe coroner identified a need for a system to ensure that advice regarding the clinical care of patients with special requirements in specialist hospitals is communicated to all treating clinicians.
Addressed to: Department of Health and Social Care; Northwick Park Hospital
AI-generated concerns summaryThe coroner noted a delay in an urgent mental health referral from Mr Smith's GP reaching the Mental Health Assessment Team, and that the reason for this delay had not been investigated.
Addressed to: Longshoot Health Centre
AI-generated concerns summaryThe hospital discharge letter sent to the GP lacked vital information, including admission and discharge details, potentially contributing to a patient's fall and subsequent subdural haemorrhage shortly after discharge.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of procedure for transferring patient information between NHS Trusts and concerns about the absence of vomiting symptoms in nursing notes, which were not communicated to the anaesthetist or surgeon. The report also questioned if asking about recent vomiting should become a standard pre-operative question.
Addressed to: St Peter’s Hospital; Wexham Park Hospital