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 regarding a doctor's fitness to practice, following a misdiagnosis and alleged misleading of parents about a second opinion, noting the doctor remains in practice.
Addressed to: General Medical Council
AI-generated concerns summaryThe coroner identified gaps in the assessment and management of tobacco withdrawal by healthcare professionals during initial prison screenings, which elevated the prisoner's vulnerability. Concerns also included insufficient healthcare input into ACCT reviews and inconsistent information sharing.
Addressed to: HMP Belmarsh; National Offender Management Service; NHS England
AI-generated concerns summaryThe coroner identified deficiencies in the Trust's post-incident review, noting it did not include interviews with a relevant service user nor explore whether other service users had left the hospital in similar circumstances.
Addressed to: Lancashire Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identified insufficient training for prison officers on escorting prisoners during hospital visits and a lack of awareness among clinicians about their power to request restraint removal. This was highlighted by a sick prisoner being restrained during examination and a subsequent uninvestigated clinician complaint.
Addressed to: Department of Health and Social Care; HMP Forest Bank
AI-generated concerns summaryThe coroner identified concerns regarding the adequacy of security measures and supervision at the care home, as a resident with dementia and a history of wandering repeatedly left the premises despite previous incidents.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner noted difficulties for Integrated Care 24 in contacting the District Nursing Service, indicating a need for improved oral and written communication methods between IC24 and district nurses.
Addressed to: Kent Community Health NHS Foundation Trust
AI-generated concerns summaryThe coroner notes a significant rate of undiagnosed breech presentations and the absence of national guidelines for routine late-stage pregnancy scans to detect them, with no national consideration of the risks, benefits, and funding implications.
Addressed to: Department of Health and Social Care; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe coroner noted concerns regarding an operating table moving uncontrollably due to issues with its handset, including possible fluid ingress and a non-functional emergency stop button. There was also a lack of hospital review for similar equipment and insufficient pre-operative checks for handset integrity.
Addressed to: Eschmann Holdings Limited; Medicines and Healthcare Products Regulatory Agency; Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in the Metropolitan Police's gathering of precise location information for railway trespassers and raised concerns about the RSSB Rule Book, suggesting it require trains to stop when an unwell person is on the line.
Addressed to: Department of Health and Social Care; LAS Legal Services; Metropolitan Police; RSSB
AI-generated concerns summaryThe coroner identified concerns regarding the Council's lack of prompt investigation and subsequent action following an injury caused by an unlicensed scaffold tower, noting this inaction may encourage others to disregard formal permission requirements.
Addressed to: Bromley Council
AI-generated concerns summaryThe coroner noted a lack of reciprocal information sharing between the Police and Mental Health Team regarding an individual's arrest and prior mental health assessment. An existing policy for mutual information sharing was not disclosed during the inquest, preventing witness questioning on it.
Addressed to: Association of Chief Police Officers; Department of Health and Social Care; Derbyshire Constabulary; Derbyshire Healthcare NHS Foundation Trust; Home Office
AI-generated concerns summaryHospital systems for sharing patient information and clinician decisions between staff were inadequate and unaudited. Also, family involvement in care decisions and providing comprehensive information to police for absent patients lacked proper systems.
Addressed to: Cygnet Healthcare Ltd.
AI-generated concerns summaryThe coroner noted that crucial low blood sugar information was not considered in the advice provided by the ambulance operator. Additionally, the ambulance service's computer program did not account for critical clinical information, leading to incorrect CPR advice.
Addressed to: Department of Health and Social Care; Welsh Ambulance Service NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of established communication procedures between general practitioners and secondary care prescribers of methadone, which led to a psychiatrist not receiving crucial patient medical information from the GP practice.
Addressed to: The Practice; The Practice; Practice
AI-generated concerns summaryThe coroner identified that the deceased was not assessed as a Vulnerable Adult at risk, which led to insufficient information sharing among professionals and hindered the implementation of preventative measures.
Addressed to: South Staffordshire and Shropshire Healthcare NHS Foundation Trust; Telford and Wrekin Clinical Commission Group; Telford and Wrekin Council; West Mercia Police
AI-generated concerns summaryConcerns were raised regarding the prison's initial risk assessment missing a known suicidal risk factor, the lack of refresher training in basic life support for officers, and a restricted cell observation window. An officer also reportedly did not visit the cell during a roll check.
Addressed to: NOMS; HMP Liverpool; Rights and Responsibilities Group
AI-generated concerns summaryThe coroner raised concerns regarding the detrimental effect of platelet transfusions following stem cell transplants and questioned whether such transfusions might be contraindicated in specific circumstances.
Addressed to: Secretary of State for Health
AI-generated concerns summaryThe coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Addressed to: National Institution for Health and Clinical Excellence
AI-generated concerns summaryThe coroner noted inconsistent availability of Omnicell cabinets across the trust and raised concerns about the risk of different fluid types being mixed up in non-critical care settings. A trust-wide review of policies for safe fluid storage, including packaging and labelling, was suggested.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Addressed to: Cambridgeshire and Peterborough NHS Foundation Trust