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 notes that unrestrained palletised loads are common practice nationwide, posing a risk to drivers. There are insufficient enforcement and auditing of road transport loading guidance by the Department of Transport.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted there is no set timeframe for medical staff to review patients admitted to the Medical Admission Unit via their GP, unlike the four-hour maximum for those admitted through the Emergency Department. This meant the deceased was not seen by a doctor for six hours after admission.
Addressed to: Rule 43 Archivist, Coroner Society of England and Wales; Office of the Chief Coroner; Royal Cornwall Hospital
AI-generated concerns summaryUncovered, high-temperature radiator pipes and valves exceeded safety guidance, posing a burn risk. The room lacked a physical risk assessment, and regulatory body inspections had not identified these issues.
Addressed to: Care Quality Commission; Health and Safety Executive, Head of Health and Social Care Services; Registered Nursing Home Association
AI-generated concerns summaryThe coroner noted a lack of clear written procedure for notifying district nurses about equipment delivery, installation, and performance review. Additionally, carers did not recognise a faulty mattress or follow the home's policy for reporting equipment faults.
Addressed to: Consumer Relations and Legal Affairs; Floron Residential Home
AI-generated concerns summaryThe coroner identified insufficient communication between the neonatal intensive care unit and the cardiac unit, which was considered unsuited for premature babies, indicating a need for improved protocols or checklists.
Addressed to: University Hospitals Bristol NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns with the transitional care cut-off weight guideline, suggesting it needed to differentiate by gestation and sex, with graphical risk presentation. There was also a need for improved joint working and staff education on hypoglycaemia and recognising unwell babies.
Addressed to: University Hospitals Bristol NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that initial home visits by Social Services and healthcare professionals were limited to one room, overlooking significant clutter in other areas. Concerns were also raised about insufficient communication between services and delays in follow-up on medication and welfare.
Addressed to: Safeguarding Adults Board; Children, Adults & Families
AI-generated concerns summaryThe coroner raises concerns about miscommunication between the control room and ambulance staff regarding instructions to 'stand down' versus 'stand back', and the lack of continual assessment of a patient's symptoms to ensure appropriate ambulance deployment.
Addressed to: South Central Ambulance Service
AI-generated concerns summaryThe coroner noted that the police use of 'excited delirium' is not widely understood by health services, potentially hindering proper diagnosis of medical emergencies. It was recommended that police training, control staff, and ambulance protocols be amended to use 'extreme agitation' to describe such conditions, ensuring appropriate prioritisation.
Addressed to: London Ambulance Service; Metropolitan Police
AI-generated concerns summaryThe coroner noted a patient was not seen by the Pain Team despite repeated attempts, and her transfer to the appropriate specialist team was delayed due to a lack of beds. This indicated she was not cared for on the correct ward or department.
Addressed to: Care Quality Commission; Milton Keynes General Hospital
AI-generated concerns summaryThe coroner identified a lack of a robust process for tracking radiology reports, leading to delays in actioning X-ray findings. There were also concerns about GPs at the Intermediate Care Unit not having access to electronic hospital notes.
Addressed to: Care Quality Commission; Milton Keynes General Hospital
AI-generated concerns summaryThe coroner noted that Neonatal Unit (NNU) staff might underestimate the risk of cardiac tamponade as a complication of TPN feeding. Concerns were also raised that NNUs may not be sharing best practices effectively to limit this complication across different units.
Addressed to: SENAT, Birmingham Woman’s Hospital and South-West Midlands Newborn Network
AI-generated concerns summaryThe coroner noted insufficient arrangements and risk management for Daniel's anti-convulsant medication, and that the supervision provided for his safety and wellbeing was inadequate.
Addressed to: Camp Village Trust; Care Quality Commission; Gloucestershire Social Services
AI-generated concerns summaryThe coroner noted that water egress from land alongside the road washed away grit, leading to black ice. A newly installed drain at the location appeared to be inadequate to prevent future occurrences.
Addressed to: Devon County Council
AI-generated concerns summaryConcerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.
Addressed to: HMP Bristol; HMP Hewell; Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner noted numerous collisions on a specific road bend and inconsistent safety signage. Approaching the bend from one direction, there were bend and 'Slow' signs but no chevron, unlike the other direction.
Addressed to: Commissioner for Transport; Staffordshire County Council
AI-generated concerns summaryThe electronic Rio record system did not migrate historical patient records, including relapse management plans for discharged patients, leaving staff unaware of important patient histories and delaying assessments.
Addressed to: Avon and Wiltshire Mental Health Partnership Trust
AI-generated concerns summaryThe coroner raises concerns about the dissemination of lessons learned from a specific incident to the wider healthcare community and other Trusts, requesting an explanation of how these lessons are being communicated.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted an absence of clear protocol guidance and a robust system for primary care physicians managing Amiodarone, along with inconsistent Shared Care Protocols across different Trusts, which could pose risks to patients and transferring staff.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryFamily requests for bed rails to be raised were not acted upon, documented, or risk assessed, and repairs were delayed. Additionally, daily statements were missing and unpaginated.
Addressed to: European Care group