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 about a community nurse administering anticoagulant medication without seeking medical advice despite previous bleeding, and failing to share this information with other professionals. The report also identified a lack of the nurse's professional insight and training.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryThe immunology team was not notified of the patient's hospital admissions, preventing their input into care and discharge. The patient was also discharged without prophylactic antibiotic medication due to a lack of a Trust-wide policy for inter-departmental admission sharing.
Addressed to: University Hospitals Leicester NHS Trust
AI-generated concerns summaryThe response to the patient's admission was uncoordinated and lacked consultant leadership. Additionally, the resuscitation room defibrillator was not charged, and no defibrillation pads were available.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner observed that the workload and working hours of two control room staff appeared to detrimentally affect their judgement and subsequent handling of the incident.
Addressed to: Avon and Somerset Constabulary
AI-generated concerns summaryThe coroner noted failures in obtaining and utilising community care assessments, developing an adequate care plan for Mrs Gibson, and conducting proper risk assessments and reduction plans. Concerns were also raised regarding a lack of cohesive management and insufficient staff training and supervision within the care home.
Addressed to: LNT Software Helios 47; Herries Lodge Care Home
AI-generated concerns summaryThe coroner raises concerns about the clarity and interpretation of BBA certificate 06/H120 for the product Milepave, noting that its wording could lead to inappropriate use on roads with higher speed limits than intended.
Addressed to: British Board of Agreement; Fletcher's Solicitors; Gloucestershire Constabulary; Gloucestershire Highways; NIG Insurance; ORJ Solicitors; Wragge & Co LLP
AI-generated concerns summaryInsufficient direct communication between District Nurses and the GP, especially regarding patient condition, wound care, and urgent blood tests. The District Nursing Team also lacked knowledge and training in burns treatment, and their wound assessment chart was inadequate.
Addressed to: Royal College of General Practitioners; Royal College of Nursing
AI-generated concerns summaryA communication breakdown between the care home, district nurses, and out-of-hours GP meant Mr O'Connell was not seen by clinical staff. There was no direct monitoring of his oral input and urinary output, and no clinical assessment for two days.
Addressed to: ABMU Health Board; Grove Medical Centre; Monkstone House Care Home
AI-generated concerns summaryThe coroner noted four deaths within three years at the Arndale Centre multi-storey car park where individuals intentionally jumped from a height.
Addressed to: Jesta Capital Corporation
AI-generated concerns summaryThe coroner noted delays in securing foetal monitoring and in performing a Category 2 C-section delivery, which exceeded Trust guidelines due to busy theatres. Expert evidence identified a real risk of preventable death due to insufficient out-of-hours theatre capacity.
Addressed to: NHS Lewisham Commissioning Group; University Hospital Lewisham
AI-generated concerns summaryThe coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Addressed to: Beeston Health Centre
AI-generated concerns summaryThe risk care plan for Mr Walker was insufficient in scope and depth and was not revisited or revised. There was no clear rationale provided for decreasing observation levels, despite the patient expressing suicidal thoughts.
Addressed to: Sussex Partnership NHS Trust
AI-generated concerns summaryOrganisations' criteria excluded the individual from care, leading to her being passed between agencies without effective intervention due to an identified lack of funding methods for such complex cases.
Addressed to: Chair
AI-generated concerns summaryThe coroner identified concerns regarding the development and deterioration of pressure sores due to inadequate nursing care, including a failure to turn patients regularly, missing care plans, and inconsistent Waterlow scoring. Additionally, nursing rotas were unavailable, understaffing was reported, and the safety of current staffing levels for high-dependency patients could …
Addressed to: Care Quality Commission; King’s College Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Addressed to: South London and Maudsley NHS Trust
AI-generated concerns summaryThe coroner identifies concerns that substandard structural repairs to Category D insurance write-off vehicles can increase injury severity in collisions. There are insufficient independent checks on such repairs before vehicles return to the road, and the MOT process may not detect compromised structural integrity.
Addressed to: Driver and Vehicle Licensing Agency; Association of British Insurers; Vehicle and Operator Services Agency
AI-generated concerns summaryAn urgent mental health assessment, requested on March 19th, 2013, was not completed before April 2nd, 2013. A timely visit by a health professional may have detected a decline in physical health, potentially allowing for active treatment to prevent death.
Addressed to: Community Mental Health Team
AI-generated concerns summaryThe coroner questioned whether providing more fresh air through opened windows in the Intensive Care Unit, rather than relying solely on recycled air conditioning, could benefit patients.
Addressed to: Queen’s Hospital
AI-generated concerns summaryConcerns were raised regarding inadequate information sharing within the prison about a person's history of self-harm and the lack of follow-up care, including a PHQ9 assessment, after antidepressant medication was prescribed.
Addressed to: Dorset Healthcare University NHS Foundation Trust; National Offender Management Service
AI-generated concerns summaryThe coroner noted the availability of fire protective aprons for smokers and raised concerns that care homes are not encouraged to provide access to these measures for residents who smoke, following an incident where a resident's clothing caught fire.
Addressed to: Care Quality Commission; South East England Fire and Rescue Service