Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified concerns regarding a doctor assessing a patient as 'Safe to Transfer' without examination, an undocumented discharge examination, and fragmented medical record systems. This risked vital clinical information being lost.
Addressed to: Department of Health and Social Care; Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted GP appointments became telephone consultations despite worsening mental health, without clear guidance on their use. There was also no mechanism for family input into the patient's mental health assessment.
Addressed to: Greater Manchester Integrated Care Board
AI-generated concerns summaryThe coroner noted that police attempting to locate an individual did not leave voicemail messages when contacting their parents, which likely delayed obtaining the correct address.
Addressed to: Avon and Somerset Police; College of Policing; Surrey Police
AI-generated concerns summaryThe coroner noted that national targets for waiting times from angiography to surgery were not being met, with current waiting times exceeding the 7-day target due to inadequate resources.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of public understanding regarding the need to report motorway problems like stationary vehicles to National Highways, observing that public information campaigns had not effectively conveyed this message.
Addressed to: Highways England
AI-generated concerns summaryThe coroner raises concerns about the lesser-known presence of nitazenes in vaping fluids and the significant overdose risk this poses. Cannabinoid vape users, often not known to drug services, may be unaware of these risks and have difficulty accessing Naloxone.
Addressed to: Advisory Council on the Misuse of Drugs; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a gap in care provision for autistic individuals in crisis, especially where there is no treatable mental health condition, and noted that the Special Allocation Scheme for GP patients was unable to meet the needs of autistic patients.
Addressed to: Devon Integrated Care Board; Devon Partnership Trust; NHS England; Primary Care NHS Devon
AI-generated concerns summaryThe coroner identified insufficient training for health visitors, midwives, and GPs in the early identification of subtle heart defects, particularly in babies born to diabetic mothers. Concerns were also raised about the lack of routine echocardiograms for high-risk babies and inconsistencies in early centile tracking for weight.
Addressed to: Department of Health and Social Care; Greater Manchester Integrated Care Board
AI-generated concerns summaryThe Trust's PSIRF Decision Monitoring Tool completed after Mr Gray died contained inaccurate information, including an incorrect record regarding self-harm and omissions about a mental health liaison nurse review and discharge.
Addressed to: Essex Partnership University NHS Trust
AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known propensity to push staff.
Addressed to: Epsom and St. Helier University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted that attending paramedics did not take Mr Wilson's significant history of heart failure into account when administering salbutamol nebulisers, which directly impacted his blood pressure.
Addressed to: North West Ambulance Service
AI-generated concerns summaryThe coroner identified a lack of appropriate falls risk assessments, insufficient documentation of safety measures, and infrequent observations for a deteriorating patient. The ward was understaffed, leading to patients being left unobserved in side rooms for extended periods.
Addressed to: North Cumbria Integrated Care NHS Foundation Trust
AI-generated concerns summaryExtremely long ambulance attendance times and persistent hospital handover delays are attributed to a lack of social care provision and community hospitals, which prevent timely patient discharge and bed availability. These ongoing issues continue to put lives at risk.
Addressed to: Betsi Cadwaladr University Local Health Board; Local Authorities within this jurisdiction; Welsh Ambulance Service Trust; Welsh Government
AI-generated concerns summaryThe coroner identified gaps in Mr Donald's discharge planning, including insufficient engagement with family and Probation Services and a lack of specific policy for direct PICU discharge. Concerns were also raised about post-discharge medication supervision and escalation of non-compliance.
Addressed to: Oxford Health NHS Foundation Trust
AI-generated concerns summaryIslington Council housed a tenant with paranoid schizophrenia and a history of attempting to jump from high windows in a sixth-floor property. The coroner noted a lack of a clear plan from the council to take such risks into account for new and existing tenants.
Addressed to: Islington Council
AI-generated concerns summaryInsufficient perfusionist staffing during out-of-hours emergency surgeries, contrary to safety guidelines, likely delayed critical intervention. The coroner highlighted concerns regarding resourcing and the availability of perfusionists to meet recommended requirements.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns were raised regarding limited on-site paediatric and medical support at the SJUH maternity site and ambiguity in its operational classification. Additionally, the coroner noted a lack of standardised national guidelines for the LISA procedure.
Addressed to: British Association of Perinatal Medicine; Department of Health and Social Care; Leeds Teaching Hospitals NHS Trust; Resus Council UK; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe treating doctor was not informed of Mr Heffer's readmission with a complication, nor was their advice sought. Additionally, medical records were incomplete and illegible, causing interpretation difficulties.
Addressed to: East Suffolk and North Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of lifeguards at the breakwater during high-risk periods, a measure previously effective at reducing dangers from jumping into the water. No satisfactory explanation was given for its removal, nor evidence for the effectiveness of current deterrents.
Addressed to: ASSOCIATED BRITISH PORTS; NEATH PORT TALBOT COUNCIL; ROYAL NATIONAL LIFEBOAT INSTITUTION
AI-generated concerns summaryPoor communication with family and power of attorney led to incorrect information on the deceased's baseline and discharge planning. Inconsistent understandings among staff of the patient's condition and absent post-discharge follow-up were also noted.
Addressed to: Addressees have not been indexed.