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 identified delays in cardiologist review, missing medical notes, and poor communication among staff and with the family. Concerns included the Do Not Attempt Resuscitation (DNAR) process lacking family discussion, and a doctor incorrectly assuming the status.
Addressed to: Tameside Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient …
Addressed to: Rotherham, Doncaster and South Humberside NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the management of the reception area before triage, which could lead to significant delays in providing immediate care, particularly for children. A more appropriate and efficient system is needed to minimise these delays.
Addressed to: Weston Area Health NHS Trust
AI-generated concerns summaryThe coroner identified delays in custody progression due to unstaffed overnight processing units, a lack of understanding among staff regarding observation levels, and inadequate record-keeping and handovers between shifts, along with issues in monitoring CCTV cells.
Addressed to: GEO AMEY; MEDACS; Greater Manchester Police
AI-generated concerns summaryThe coroner noted concerns regarding a widespread work method used in the industry and the need for risk assessments to be properly disseminated and explained to staff operating the process.
Addressed to: British Precast Concrete Federation
AI-generated concerns summaryThe coroner noted a lack of recorded vital signs and impressionistic assessment of physical symptoms, which meant healthcare staff were unaware of a dehisced bowel anastomosis and internal abscess leading to a catastrophic infection.
Addressed to: Newcastle upon Tyne Hospitals NHS Foundation Trust; North of England Commissioning Report; South Tyneside NHS Foundation Trust; Trinity Medical Centre
AI-generated concerns summaryThe coroner noted that not all of the company's vehicles, particularly those laden with aggregates and travelling on public highways, are weighed prior to their departure from the premises.
Addressed to: Lightwater Quarries Limited
AI-generated concerns summaryThe coroner identified that a central illuminated bollard could obstruct motorists' views and that non-prescribed road markings might lead pedestrians to believe they have priority.
Addressed to: North East Lincolnshire Council
AI-generated concerns summaryThe coroner noted concerns regarding the failure to identify an individual as a vulnerable person, despite clear indicators, leading to power disconnection without adequate customer protection. Additionally, staff felt disempowered to intervene, and current protective measures are not industry-wide or permanent.
Addressed to: Energy UK; Npower; Ofgem
AI-generated concerns summaryThe coroner identified a need for improved information sharing with the Fire Service about vulnerable individuals at risk of fire. Where information cannot be shared, local authority staff could receive training to conduct home fire safety checks.
Addressed to: Carmarthenshire County Council County Hall; Pembrokeshire County Council Hall
AI-generated concerns summaryThe coroner noted a potential low awareness of Sudden Arrhythmic Death (SAD) in general practice, alongside an apparent lack of, or awareness of, guidelines for GPs regarding urgent referrals for patients vulnerable to SAD.
Addressed to: British Cardiovascular Society; Royal College of General Practitioners
AI-generated concerns summaryThe coroner identified gaps in Trust guidelines for competence and training for a suprapubic procedure. Concerns were also raised about the performing consultant's infrequent practice and the pre-procedure difficulty in locating necessary equipment.
Addressed to: England & Wales; Pennine Acute Trust
AI-generated concerns summaryConcerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryUnqualified administrative staff categorised urgent mental health referrals without clinical review or re-prioritisation by nursing staff. The coroner also identified a lack of robust systems for tracking non-contact referrals and managing the high workload of Senior Nurse Practitioners.
Addressed to: 5 Boroughs Partnership NHS Foundation Trust
AI-generated concerns summaryLondon Underground lacked a process to simultaneously shut down intersecting lines and an effective method to alert train drivers to a person on the track.
Addressed to: London Underground
AI-generated concerns summaryRequired one-to-one nursing was not consistently available, and a lack of direct orthopaedic input in the Emergency Department led to unnecessary admission. Also noted were incomplete fluid balance charts and staff difficulties with the computer system.
Addressed to: Royal Bolton Hospital
AI-generated concerns summaryThe coroner noted issues with Mr Collins' initial assessment in A&E, the failure to perform hourly nursing observations, and incomplete nursing documentation. Concerns were also raised about the management and accessibility of hand sanitiser gel.
Addressed to: Cleveland Police; Tees, Esk and Wear Valleys NHS Foundation Trust; James Cook University Hospital, South Tees NHS Trust
AI-generated concerns summaryThe hospital did not investigate the cause of a patient's fall as a Serious Untoward Incident, and appropriate electronic records were not made. It was also unclear if falls prevention training and recording protocols applied to all staff.
Addressed to: North Middlesex University Hospital NHS Trust
AI-generated concerns summaryThe GP surgery experienced delays in receiving and reviewing hospital discharge letters, lacking a method to differentiate between serious and non-serious injuries for prompt attention. Strong painkillers were prescribed over the phone without a face-to-face review, despite the patient's complex medical history and multiple rib fractures.
Addressed to: Nuffield Road Medical Centre
AI-generated concerns summaryThe coroner raised concerns about the allocation of Mr Peters' case to an officer on leave, insufficient prioritisation of the assessment, and the absence of a system to reallocate cases that could not be completed within the required 28-day period.
Addressed to: Bolton Council