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 summaryA resident's fall was not contemporaneously documented, leading to missed opportunities for medical examination despite her deteriorating condition. Concerns were raised about insufficient incident recording, record auditing, and staff training.
Addressed to: Green Range Limited
AI-generated concerns summaryThe coroner raises concerns needing a full review of cockpit fire/smoke procedures, including oxygen fire recognition and protective equipment. The report also notes the need to amend international civil aviation rules regarding participating states' investigation rights and access to evidence.
Addressed to: Civil Aviation Authority; Department for Transport; European Aviation Safety Agency; Stewarts Law
AI-generated concerns summaryThe coroner highlighted sub-standard practice where a GP failed to perform a basic vascular examination on a patient with a foot wound and leg pain, contrary to national guidelines.
Addressed to: Alexandra & Crestview Surgeries
AI-generated concerns summaryThe care home accepted a patient requiring one-to-one care despite knowing they could not provide it. An outsourced carer also had insufficient understanding of the patient's complex needs and communication difficulties.
Addressed to: 1st Care 4U; Holcroft Grange; Minster Care Group
AI-generated concerns summaryThe coroner raised concerns regarding poor clinical documentation, including a lack of recorded observations, key events, and inter-organisational discussions, which could lead to an incomplete patient picture and future risks.
Addressed to: East Kent Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inconsistencies between two scoring systems used for infection assessment, raising a need for a single, consistent system. Concerns were also noted regarding the need for improved tools for early sepsis identification and the potential for critical information to be lost during 111/999 handovers due to Interoperability Toolkit …
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe Trust did not conduct a serious incident investigation into the progression of a patient's wound under District Nurse care. Furthermore, a recommended orthopaedic follow-up after an initial Emergency Department attendance did not take place.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of diligent focus on risk assessment and mitigation at North Court Care Home, where staff regularly failed to implement identified measures. This included failing to secure bed rails, which was described as a potential cultural problem affecting multiple staff.
Addressed to: North Court Care Home – Maven Healthcare
AI-generated concerns summaryThe coroner noted a gap in the availability of the time-critical thrombectomy emergency procedure for severe stroke patients in the South West region.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted insufficient falls prevention assessments and documentation, a delayed medical review after an inpatient fall, and a lack of family communication about scan findings, indicating non-compliance with Trust policies.
Addressed to: Rotherham NHS Foundation Trust
AI-generated concerns summaryThe coroner identifies persistent, excessive ambulance handover delays and a significant disconnect between ambulance service expectations and hospital performance. This leads to prolonged waits for acutely unwell patients, with similar risks remaining in the system.
Addressed to: First Minister of Wales
AI-generated concerns summaryThe coroner identified a lack of specific staff training at Ty Bargoed on identifying and mitigating falls risks, with materials focusing on post-fall management rather than prevention. Concerns also included the absence of a falls prevention policy and unclear follow-up actions by MTCBC's Health and Safety Unit on falls notifications.
Addressed to: Merthyr Tydfil County Borough Council
AI-generated concerns summaryConcerns were raised about inadequate staffing, medical facilities, and overcrowding in the A&E department, resulting in patients in corridors not receiving appropriate care. Additionally, the department lacks sufficient resuscitation beds, an electronic observation system, and Critical Care Outreach Team support for deteriorating patients.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe West Yorkshire Integrated Care Board has not commissioned the accessibility of NHS 111 online assessment outcomes for Emergency Department clinicians at Mid Yorkshire Teaching NHS Trust. This means crucial patient history, such as suspicion of pulmonary embolism, is not readily available to clinicians.
Addressed to: West Yorkshire Integrated Care Board
AI-generated concerns summaryThe coroner identified concerns that detained adult patients with internet access can circumvent monitoring, allowing them to research means to end their lives. There is a need for clearer national rules, guidance, and technological investment to reduce this risk.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a continuing lack of a commissioned specialist service for GPs to refer patients to for safe reduction and withdrawal from prescribed dependency-forming medications, which presents a risk of future deaths.
Addressed to: Department of Health and Social Care; Mid and South Essex Integrated Care Board; NHS England & NHS Improvement
AI-generated concerns summaryThe coroner identifies that inconsistent definitions of a "month" for diabetic medication prescriptions can impede patients obtaining timely repeat supplies. This impacts medication consistency and may lead to serious health risks, an issue not addressed in professional guidance.
Addressed to: Royal Pharmaceutical Society
AI-generated concerns summaryThe coroner identified no system to prevent staff non-compliant with mandatory training, including basic life support, from working on in-patient wards, which is particularly relevant for elderly patients at higher risk of medical collapse.
Addressed to: Essex Partnership University NHS Trust
AI-generated concerns summaryThe coroner noted widespread non-compliance with daily skin inspections, infrequent updates to care plans, and delays in specialist referrals for wound deterioration. Concerns also included lost records and a lack of clear staff guidance on pressure damage management.
Addressed to: Red Oaks Care Community
AI-generated concerns summaryConcerns are raised about the limited rehabilitation options for stroke patients, specifically the lack of a step-down community facility for those not eligible for inpatient care but unsafe at home. This places individuals at risk when discharged home.
Addressed to: Department of Health and Social Care