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 identified that the Trust failed to provide care plans for patients discharged from their wards to other establishments, raising a risk of future deaths.
Addressed to: Somerset Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about time pressures on the Range Conducting Officer to complete exercises, noting that the Exercise Director must ensure sufficient time is allocated for final assurance checks.
Addressed to: House of Commons
AI-generated concerns summaryThe coroner noted that road transfer times for critically ill patients, especially neurosurgical emergencies, between distant hospitals and specialist facilities may not allow sufficient time for life-saving interventions. Healthcare staff needing urgent transfers were advised to consider air transfer first.
Addressed to: NHS England
AI-generated concerns summaryKent Police improperly asked the deceased's family to make a decision on organ donation that is legally the coroner's responsibility. A police officer subsequently subverted the coroner's judicial decision by pressuring the grieving family.
Addressed to: Kent Police
AI-generated concerns summaryThe coroner noted the recurrence of similar circumstances in multiple previous inquests involving the Trust and recommended an independent assessment.
Addressed to: Care Quality Commission; Department of Health
AI-generated concerns summaryThe coroner identified a lack of protocol requiring locum doctors to report difficulties in contacting patients to operatives, which prevented further follow-up action.
Addressed to: Harmoni
AI-generated concerns summaryThe coroner noted insufficient staffing levels to assist residents with eating, and a high reliance on agency staff. This raised concerns that some residents requiring feeding assistance might not receive it.
Addressed to: Moundsley Hall Nursing Home
AI-generated concerns summaryThe presence of wheeled chairs on wards where elderly patients at high risk of falls are cared for, and the lack of available alarms for these patients when one-to-one assistance is needed, raises concerns.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a need for clearer guidance on assessing self-harm risk and ensuring patient safety, including clarification on not leaving at-risk patients alone and confidentiality. Concerns also related to doctors consulting with patients before and after prescribing medication with an increased self-harm risk.
Addressed to: Department of Health
AI-generated concerns summaryThe coroner noted that written allergy warnings on hospital documentation were overlooked and suggested clearer indications on patient files. Concerns were also raised about inadequate handovers during patient transfers, where the accompanying nurse had insufficient knowledge of the patient's condition.
Addressed to: United Lincolnshire Hospital Trust
AI-generated concerns summaryThe coroner noted the absence of a clear written plan or guidance for staff regarding responses to head injuries in elderly residents, particularly those on anti-clotting medication, a gap that may affect other council-operated homes.
Addressed to: Cumbria County Council Carlisle; Cumbria County Council Carlisle
AI-generated concerns summaryThe coroner identified unclear observation times and a missing observation sheet from medical records, alongside inconsistent understanding among nursing staff regarding patient observation requirements during bathing.
Addressed to: Camden & Islington NHS Foundation Trust
AI-generated concerns summaryThe Trust's guidelines for umbilical venous catheter (UVC) insertion, specifically requiring an X-ray to confirm placement, were not followed. The coroner raises concerns about the absence of national UVC guidelines and the need for review and training.
Addressed to: Liverpool Womens Hospital
AI-generated concerns summaryThe coroner noted the absence of a face-to-face meeting with the deceased before revoking firearms certificates, and that the revocation letter was not personally served by police, with the decision communicated via family.
Addressed to: Durham Constabulary
AI-generated concerns summaryThe coroner identified a need for guidance on the interpretation of 'where possible' in policy OPO6O for intentional overdose calls. It was suggested a supervisor should be consulted before ending such calls when the person is alone.
Addressed to: London Ambulance Service
AI-generated concerns summaryThe coroner noted the Council's failure to review its night-lighting policy regarding pedestrian safety, particularly where a footpath discontinues and pedestrians regularly use the road during unlit hours.
Addressed to: Warwickshire County Council
AI-generated concerns summaryThe patient was discharged without a summary, written information about her laparoscopic operation, contact telephone numbers for advice, or details on matters requiring urgent medical assistance.
Addressed to: Aintree Hospitals NHS Trust
AI-generated concerns summaryThe coroner highlights confusion regarding unbordered blue strips on cycle super highways, which may cause cyclists and motorists to misjudge priority and safe positioning. There is also a need for more education on safer riding techniques and improved infrastructure at a specific junction.
Addressed to: Transport for London
AI-generated concerns summaryThe coroner noted concerns regarding the circumstances in which the deceased fell into the sea during a medical evacuation rescue.
Addressed to: Cruise and Maritime Services International Limited; Newmarket Promotions Limited; Redningsselskapet
AI-generated concerns summaryThe coroner highlighted concerns about 'alert fatigue' within a medical practice, where a doctor prescribed a drug despite an adverse reaction alert. The report notes potential issues with the alert system, clarity of alerts, and staff training.
Addressed to: Castlefields Health Centre; NHS England