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 Trust's governance failed to identify the case as an incident requiring investigation through the Patient Safety Framework. This indicated inadequacies in its Datix incident reporting system, morbidity and mortality meeting process, and PSIRF procedure.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe haematology department was understaffed and operating beyond its capacity, leading to insufficient time for comprehensive patient reviews. This situation was noted to be ongoing.
Addressed to: Birmingham and Solihull Integrated Care Service; Department of Health and Social Care; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient bed availability in psychiatric units to meet patient demand.
Addressed to: Department of Health and Social Care; Gloucestershire Health & Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that temporary road signage, while compliant with national guidance and regulations, was inadequate at the collision site. This raises concerns that the current national regulations for temporary signage may be insufficient and represent a wider issue.
Addressed to: Department for Transport
AI-generated concerns summaryLack of information available to GPs creates a risk of patients receiving either no medication or excessive medication due to potential duplicitous prescribing.
Addressed to: NHS Sussex; Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in calling an emergency ambulance for an unresponsive resident and identified significant concerns about the adequacy and accuracy of care home record-keeping, including misleading and unlabelled retrospective entries. Insufficient reassurance was provided that these risks were reduced.
Addressed to: Barchester Healthcare Ltd
AI-generated concerns summaryConcerns were raised about the supported accommodation's unclear role in medication supervision and a significant lack of communication between its staff and the mental health unit regarding changes in a resident's mental state and the escalation of deterioration.
Addressed to: Riverside Group Limited
AI-generated concerns summaryThe coroner identified insufficient social care provision impeding hospital discharge, contributing to significant ambulance handover delays and emergency department crowding. These issues collectively increased mortality risks for patients in the community and within the hospital environment.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified insufficient guidance for managing profoundly disabled children in hospital, inadequate parental consultation leading to poor clinical decisions, staff not acting on observations, and the absence of a Learning Disability Liaison Nurse.
Addressed to: Care Quality Commission; Department of Health and Social Care; NHS England; Royal College of Emergency Medicine; Royal College of Paediatrics; Royal Surrey County Hospital NHS Foundation Trust
AI-generated concerns summaryLB Croydon Adult Social Care could not access NHS LIFE team assessment records, including documented risk assessments and telecare advice from hospital discharge, hindering proper review of clients' post-discharge needs.
Addressed to: London Borough of Croydon
AI-generated concerns summaryThe ambulance service's MDPS system may not be sufficiently nuanced to distinguish between different types of abdominal surgical emergencies, potentially leading to an inappropriate disposition and delayed conveyance to hospital.
Addressed to: NHS England
AI-generated concerns summaryClinicians regularly miss or misunderstand ECG readings, and there is no clear national guidance for the pathway of children with paediatric exercise-induced syncope. Additionally, the assessment for exercise-induced asthma was insufficient, delaying the diagnosis of an underlying cardiac condition.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a prolonged hospital stay due to a lack of a clear discharge strategy and insufficient collaboration between two trusts, which contributed to the patient's decline. Additionally, poor quality documentation by GMMH meant staff lacked full insight into the patient's needs and decisions.
Addressed to: Greater Manchester Integrated Care Board; Greater Manchester Mental Health; Manchester University NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns that wide and clawed ferrules for walking sticks lack warnings about potential risks if stood on or trapped, especially when used with folding/collapsible sticks.
Addressed to: Office for Product Safety and Standards
AI-generated concerns summaryThe coroner raises concerns that blood gas machine displays for unrecordably low blood glucose levels can be misinterpreted, potentially delaying appropriate clinical responses. The report notes the display '- - -↓' may be seen as an unanalysable sample rather than an extremely low reading.
Addressed to: Medicines and Healthcare Products Regulatory Agency
AI-generated concerns summaryThe coroner identified that the hospital trust's use of multiple, unintegrated IT systems for patient records risks significant findings being overlooked and slows clinical decision-making. This issue, which can also impact transfers of care, appears to be present nationally.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns exist regarding ongoing delays in ambulance response and the provision of pre-hospital emergency care, as average response times for Category 2 calls significantly exceed the target due to multi-factorial issues within the wider health system.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that the current vehicle licensing system, relying on drivers to self-report medical conditions, may not adequately address the risks posed by increasing numbers of older drivers with declining mobility and cognitive function. This creates a risk of future deaths due to compromised driving ability.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted a high number of road traffic collisions and fatalities at Loscombe Crossroads and raised concerns about the road layout, despite a recent speed limit reduction.
Addressed to: Department for Transport; Dorset Council
AI-generated concerns summaryThe coroner noted that children needing one-to-one care sometimes received less supervision and identified insufficient communication with external authorities and next of kin. Concerns also included staff training and the thoroughness of internal investigations.
Addressed to: Children’s Trust