Browse 6,470 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 the appropriateness of surgical procedures for elderly patients, particularly regarding conservative measures and treatment choice guidance. Insufficient accuracy in handover communications for patients returning from HDU was also identified.
Addressed to: Department of Health and Social Care; NHS England; Stepping Hill Hospital
AI-generated concerns summaryThe coroner noted insufficient information sharing from Nottinghamshire Police to Adult Social Care, specifically that previous Public Protection Notices (PPNs) are not always shared when a current PPN is referred, potentially leading to incomplete information for decision-making.
Addressed to: Nottinghamshire Police
AI-generated concerns summaryInsufficient physical barriers prevent public access to railway tracks from platforms, and platforms are not designed to deter suicide attempts. Additionally, train crews did not report the individual's presence on the tracks, potentially due to poor visibility.
Addressed to: Network Rail
AI-generated concerns summaryConcerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Addressed to: DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC); National Institute for Health and Care Excellence; NHS Derby and Derbyshire Integrated Care Board; NHS Derbyshire Healthcare NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner raised concerns that the known hazard of the P1 terminal design was not replaced due to financial limitations, which presents an ongoing safety risk for vehicles on designated roads.
Addressed to: National Highways
AI-generated concerns summaryThe coroner noted concerns about the inherent risk of death for patients who remain for lengthy periods in the Emergency Department’s ‘Rapid Assessment and Triage’ Corridor, as it is not designed for observations and providing care.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryA locum doctor discharged a patient without reviewing the second part of a CT scan report, missing a pulmonary embolism. The Trust lacks assurance that all existing locum doctors are trained on this two-part reporting process, risking undiagnosed conditions.
Addressed to: Worcestershire Acute Hospital NHS Trust
AI-generated concerns summaryThe coroner identified insufficient staffing within the community nursing team, which led to missed patient appointments and an inability to meet the increasing demand from more complex cases.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted the absence of a risk assessment to warn workers about the dangers of using machinery near electrical equipment on the estate. This specific risk assessment remains outstanding at other sites owned by the company.
Addressed to: Kenny & Murphy Limited
AI-generated concerns summaryThe coroner raised concerns that the mental health crisis team's capacity determines same-day assessment for patients needing it, and that the Trust does not seek additional resources when the local crisis team has no capacity.
Addressed to: Gloucestershire Health and Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clinical handover to the receiving ward and no doctor's instructions for cardiac monitoring. The patient's medication was found in her belongings, allowing an opportunity for further overdose.
Addressed to: James Paget University NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues with clinicians in different health trusts unable to access each other's medical records, resulting in treatment without a full clinical picture. Concerns also included untimely outpatient follow-up and a hospital discharge without prescribed antibiotics against microbiologist advice.
Addressed to: Royal Devon University Healthcare NHS Foundation; Somerset NHS Foundation Trust (Musgrove Park Hospital Trust)
AI-generated concerns summaryThe coroner identified that the investigation of a pulmonary embolism did not follow NICE guidance, and a CT pulmonary angiogram was rejected without a D-dimer test being completed. An urgent review of the hospital's relevant policy and procedure is needed.
Addressed to: Milton Keynes University Hospital
AI-generated concerns summaryThe coroner noted that road traffic collision data, reviewed annually, is not immediately reported to the Highways Department, potentially delaying timely safety improvements to highway conditions.
Addressed to: Lincolnshire County Council; Lincolnshire Police
AI-generated concerns summaryThe coroner noted the absence of a nationwide policy or approach for anti-ligature measures within mental health settings.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified inaccurate record keeping practices, including staff using other's ID cards, and a widespread lack of understanding regarding therapeutic engagement among ward staff. Additionally, the trust's systems for safe patient transition from intensive to acute care were inadequate, failing to facilitate identified risks.
Addressed to: North London NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a fundamental lack of serial nursing observations in Finlay’s care, noting concern that this issue may be widespread. Additionally, medical staff at the Whittington did not recognise the absence of observations, leading to discharge without them being carried out.
Addressed to: Royal College of Emergency Medicine; Royal College of Nursing; Royal College of Paediatrics and Child Health; Whittington Health NHS Trust
AI-generated concerns summaryThe coroner noted a lack of staff understanding regarding Speech and Language Therapy and Dietetic Service guidelines for managing aspiration risk. There were also concerns about insufficient cooperation and shared clinical responsibility between the two NHS Trusts involved.
Addressed to: Central North West London NHS Foundation Trust; Milton Keynes University Hospital
AI-generated concerns summaryThe coroner identified inadequate face-to-face weight monitoring and assessment across GP, CAMHS, and dietetics services. Concerns were also raised regarding confusion over Consultant-to-Consultant referral guidance, leading to delays in referrals.
Addressed to: 49 Marine Avenue Surgery; Department of Health and Social Care; Moorbridge School; North East and North Cumbria Integrated Care Board; Northumbria Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the prescription of a four-week supply of medication to Mr Viles, made after a psychologist had raised significant concerns about his mental health and suicidal ideation.
Addressed to: Complex Spine Clinic; Princess Grace Hospital