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 noted unacceptable delays in patient handover from ambulances to the Emergency Department, which results in ambulance resources being unavailable for other calls.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted the absence of smoke detectors in the property and that fire safety check procedures were not in place. The report recommends the property owner inspect all housing stock to ensure hard-wired or battery-operated smoke detectors are fitted.
Addressed to: Leeds City Council
AI-generated concerns summaryThe coroner noted a lack of formal handover between GPs when the patient changed doctors, and that a care plan from the Community Mental Health Team was not actioned upon receipt. This resulted in primary care being unaware of the patient's fluctuating mood.
Addressed to: Royal Cornwall Hospital Trust; Medical Centre; Stratton, Bude, Cornwall
AI-generated concerns summaryThe coroner identified a lack of dedicated substance misuse teams for detainees in police custody and for patients in hospitals. Concerns were also raised regarding the alignment of handcuffing policies for seriously ill detainees with ACPO guidance.
Addressed to: Association of Chief Police Officers; Department of Health and Social Care; G4S; Serco
AI-generated concerns summaryThe coroner noted that a take-away meal consumed by Jackie Scott contained peanuts or peanut oil, of which he was unaware, leading to a fatal allergic reaction.
Addressed to: Indian Brasserie
AI-generated concerns summaryA lack of formal consultation with carers or partners of mental health service users limits comprehensive risk assessment, especially for domestic abuse involving the elderly. Concerns were also raised about ensuring locally learned lessons are shared nationally.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns regarding protocols for pre-Infliximab tuberculosis screening, the awareness of healthcare professionals about TB risk, and the need for ongoing patient education. Additionally, prompt treatment initiation for suspected tuberculous meningitis was highlighted.
Addressed to: British National Formulary; British Society of Gastroenterology; Intensive Care Society; Lincolnshire Community Health Services NHS Trust; Medicines and Healthcare products Regulatory Agency; Phoenix Partnership; United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryDoctors did not access and read all relevant information, including nursing notes, leading to a delay in actioning critical information that was available in Mr Felstead's medical records.
Addressed to: Care Quality Commission; Stepping Hill Hospital; Choice Support
AI-generated concerns summaryThe coroner noted the bend at this location is a collision black spot and suggested improving chevron signs with yellow backgrounds and painting "SLOW" on the carriageway. Concerns were also raised about a eucalyptus sapling that will mature into a potential hazard.
Addressed to: Department for Transport; National Highways; The Chief Coroner
AI-generated concerns summaryThe coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
Addressed to: Tameside General Hospital
AI-generated concerns summaryThe coroner noted a lack of routine patient weighing, poor medical record keeping, and confusion regarding the funding and logistical arrangements for a prisoner seeking private healthcare outside the prison, further complicated by a lack of formal policy.
Addressed to: Department of Health and Social Care; National Offender Management Service
AI-generated concerns summaryThe coroner noted concerns about an unregulated product readily available to consumers, with little or no information on safe dosage or potential consequences.
Addressed to: Home Office
AI-generated concerns summaryThe DWP assessing doctor did not take into account the views of Mr O'Sullivan's treating doctors. Additionally, the non-medically qualified ultimate decision maker did not request or review any reports from these medical professionals.
Addressed to: Department for Work and Pensions
AI-generated concerns summaryNursing home staff failed to recognise an acutely unwell resident or act on low blood pressure, exacerbated by a lack of ongoing training. Managers also did not effectively investigate incidents and provided inaccurate reports to the Care Quality Commission.
Addressed to: Care Quality Commission; Nursing and Midwifery Council; St Mary’s Nursing Home; West Midlands Ambulance Service University NHS Foundation Trust
AI-generated concerns summaryThe coroner notes a lack of appropriate criteria for assessing the wind effects of tall buildings on highway users' safety. There is also a need for guidance to planning authorities to consider these wind effects on all road users.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Addressed to: Browning Street Surgery; General Medical Council
AI-generated concerns summaryConcerns were raised about a patient with a head injury waiting over 90 minutes for ambulance conveyance. The coroner noted insufficient ambulance crews in the area and protocols for emergency calls that may put patients at risk.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryDuring GP consultations for a patient with depression and a history of self-harm, the coroner noted no reference to Mental Health Services, nor was advice sought regarding previous involvement or need for further input.
Addressed to: King Street Medical Centre
AI-generated concerns summaryThe coroner identified the lack of availability of a specialist diabetic nurse at the hospital over the weekend.
Addressed to: Barnet and Chase Farm Hospitals NHS Trust; Department of Health and Social Care
AI-generated concerns summaryInsufficient staffing levels in the Emergency Department led to doctors being overwhelmed and significant treatment delays, particularly for patients with severe health issues, exacerbated by the volume of minor complaints.
Addressed to: Stockton NHS Foundation Trust