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 insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Addressed to: Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner highlighted that no medical opinion was sought for a resident remaining unconscious for a prolonged period after a suspected fit, delaying the diagnosis of an intracerebral haemorrhage. This approach places future residents with treatable conditions at risk.
Addressed to: Springbank Care Home Limited
AI-generated concerns summaryThe coroner noted inconsistencies in whiteboard use across Wales, raising concerns about potential over-reliance on whiteboards instead of patient notes, the risk of human error leading to incorrect information, and the possible continued use of a "DNR red star" system in some health board areas.
Addressed to: Cardiff and Vale University Health Board; Welsh Government Health and Social Care
AI-generated concerns summaryThe coroner noted issues with medical equipment design, specifically syringe caps not being brightly coloured or visually distinct, and a lack of awareness among surgical teams that certain syringes now come with caps. Concerns also included the absence of a standard procedure for counting or checking these caps after operations.
Addressed to: Care Quality Commission; Department of Health and Social Care; Secretary of State for Health
AI-generated concerns summaryThe coroner raised concerns regarding the ambulance service's call priority allocation, which led to diversions, and insufficient system resilience, particularly in rural areas. Additionally, communication with callers about estimated arrival times and potential delays was identified as needing review.
Addressed to: South Central Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns following several deaths of intoxicated young men falling into the River Trent, identifying a need for a review of safety measures. The report suggests considering further actions such as fencing or warning signs at main river access points.
Addressed to: East Staffordshire Borough Council
AI-generated concerns summaryThe coroner noted an alleged incident where a patient fell was not recorded, raising concerns that staff may not be adequately reporting all inappropriate incidents, even when major harm is not immediately apparent.
Addressed to: Burton Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the threshold for determining adequate telephone versus home consultations, the need for full mental capacity assessments when patients refuse treatment, and proper documentation of these discussions.
Addressed to: HAMA Medical Centre, NHS Commissioning Board Derbyshire and Nottinghamshire, Ministry of Justice
AI-generated concerns summaryThe Trust's Psychiatric Intensive Care Services policy lacked a clear inpatient referral process and required no written response in patient notes. Resuscitation training for nursing staff was unclear and misinterpreted guidelines, compounded by misleading aide-mémoires on equipment.
Addressed to: Surrey and Borders Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner identified significant errors in internal Serious Untoward Incident investigations, suggesting independent oversight is needed. Concerns were also raised about inadequate patient handover, particularly a lack of review of recent records for new patients.
Addressed to: APEX Nursing Agency; Care Quality Commission; Department of Health and Social Care; Greater Manchester Mental Health NHS Foundation Trust; NHS England; NHS Manchester Clinical Commissioning Group; NHS North Western Deanery; Manchester Mental Health and Social Care Trust
AI-generated concerns summaryThe coroner raised concerns regarding the absence of records for resident flood reports, an unverified assumption about land ownership, and a subsequent three-month period of inaction to address the flooding issue. There was no formal written communication to establish responsibility, leading to delays in resolving the hazard.
Addressed to: David Bowe
AI-generated concerns summaryMs Ferguson's hospital discharge occurred without notifying Social Services, despite their recommendations, and communication with her friend regarding post-discharge supervision lacked clarity. Incomplete hospital notes also hindered tracing key decisions and the precise discharge date.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust”
AI-generated concerns summaryThe coroner raised concerns about multiple deaths at the premises and the lack of 24-hour supervision at a homeless unit. This allows drug users residing there to introduce others out of hours, creating risks for all present.
Addressed to: Riverview, 62 Lound Road, Kendal; Riverview, 62 Lound Road, Kendal
AI-generated concerns summaryThe coroner noted that police officers were unaware of excited delirium at the time of the incident and raised concerns about whether awareness training on this condition is now standard across all police forces in England and Wales.
Addressed to: National Crime Agency
AI-generated concerns summaryThe coroner raised concerns about insufficient paediatric first aid training among nursery staff and expired certifications. Issues were also identified with an ambulance call-taker's misinterpretation leading to incorrect triage, and a lack of suitable paediatric life-saving equipment in emergency ambulances.
Addressed to: North West Ambulance Service Trust; Department for Education; Department for Health
AI-generated concerns summaryRadiographers and clinicians at Derriford Hospital cannot access patient allergy information recorded on different computer systems within the hospital or from other hospitals. There is also insufficient awareness among nursing staff regarding Chlorhexidine as a cause of anaphylactic reactions.
Addressed to: Derriford Hospital, Plymouth
AI-generated concerns summaryDischarge information from NHS hospitals to the prison was often delayed by up to 10 days and incomplete, with attempts to obtain manuscript forms frequently unsuccessful.
Addressed to: Secretary of State for Health; the NHS; HMPS; HMP Manchester; major NHS Trusts in Greater Manchester; Minister for Prisons
AI-generated concerns summaryThe coroner identified that AMT, a 'legal high', is readily available for purchase online and in the community, and has been linked to several deaths due to its deadly effects.
Addressed to: House of Commons
AI-generated concerns summaryThe coroner noted an inadequate mobility assessment for Mrs Jones, leading to her unsafe placement in a stand aid while non-weight-bearing. Concerns also included insufficient staff awareness of her limitations and safe equipment operation.
Addressed to: Abbeydale Residential Home, Princes Drive, Colwyn BayRoad
AI-generated concerns summaryThe coroner raised concerns about the narrow and acute bends on the bridleway, which provide no margin for error. Additionally, there is an absence of barriers between the track and the river, risking vehicles leaving the track and entering the water.
Addressed to: The Peak District National Park Authority