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 noted that a Grade 4 pressure sore, likely present prior to discharge from Queen Elizabeth Hospital, was not properly inspected for or adequately documented in patient notes during the hospital admission.
Addressed to: UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
AI-generated concerns summaryThe hospital arranged Mr Brookes' transportation home without ensuring his care was rearranged, and no process existed to document this. Additionally, Mr Brookes was unable to call for help as his alarm pendant and phone were not accessible.
Addressed to: Russells Hall Hospital
AI-generated concerns summaryThe nursing home's pre-transfer assessment process was not robust enough to ensure all relevant patient information, such as blood sugar monitoring frequency, was received for safe care, partly due to a lack of face-to-face assessments.
Addressed to: Betsi Cadwaladr University Health Board; Pendine Park Care Organisation
AI-generated concerns summaryThe coroner raises concerns that high-risk medical equipment, such as lap belts, is readily available for purchase online by the public without warnings about associated risks or guidance from healthcare professionals.
Addressed to: Department of Health and Social Care; Medicine and Healthcare Products and Regulatory Agency
AI-generated concerns summaryConcerns exist regarding lengthy national and local waiting times for ASD assessments, which are important for guiding care and mitigating risks for individuals with an ASD diagnosis. Separately, safety measures on a bridge do not meet current guidance.
Addressed to: Hertfordshire County Council; Hertfordshire & West Essex Integrated Care Board; NHS England
AI-generated concerns summaryConcerns were raised about care home staff communication and integrity due to conflicting accounts of patient feeding. Additionally, staff lacked the clinical skills to initiate CPR for a patient in cardiac arrest from a potentially reversible cause.
Addressed to: Lukka Care Homes Limited
AI-generated concerns summaryThe coroner noted complexities in care for patients with dual diagnoses due to separate mental health and substance misuse services. An ongoing review of this issue does not consider the additional challenges when these patients are also homeless, causing confusion over care provision and funding.
Addressed to: Department of Health and Social Care; Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner noted communication difficulties between the patient's family/housing and the mental health trust, with unanswered calls and no system to manage messages when the care coordinator was absent. Additionally, the patient's case lacked a priority coding for regular review.
Addressed to: South West London and St George’s Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted a lack of regulation and oversight for open water swimming events, with no established body providing specific health and safety guidance. This leads to inconsistent safety measures, inadequate briefings, and insufficient participant monitoring.
Addressed to: Department for Culture, Media and Sport; Health and Safety Executive
AI-generated concerns summaryThe coroner noted insufficient urgent safeguarding action for a child despite disclosures of fear and self-harm intent. Concerns also include a lack of multi-agency information sharing and no clear system for urgent cross-agency meetings to assess child safety.
Addressed to: Department of Health and Social Care; Kent and Medway Integrated Care Board; NHS England
AI-generated concerns summaryThe coroner noted significant waiting lists for Interpersonal Psychotherapy and other mental health services, with demand far exceeding commissioned capacity. This results in prolonged waits for individuals identified as requiring mental health therapy support.
Addressed to: Greater Manchester Integrated Care Board; Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified obstructed visibility at a junction on the A534 due to signage and turning vehicles, combined with traffic accelerating into a national speed limit zone, creating a risk of future collisions.
Addressed to: Wrexham County Borough Council
AI-generated concerns summaryA care home operated with insufficient management and inadequate communication with families and regulators. Significant ambulance handover delays to the Emergency Department also led to patient waits for antibiotics and beds due to high demand.
Addressed to: Care Quality Commission; Department of Health and Social Care; Tameside Metropolitan Borough Council
AI-generated concerns summaryThe coroner noted a lack of specific guidance on how to incorporate Executive Dysfunction into mental capacity assessments for adults with Hoarding Disorder, and when external intervention can be triggered.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of clear, mandatory standards within the Fire Safety Order 2005 regarding specific fire safety measures, risk assessment conduct, and record-keeping for businesses offering paid accommodation. This results in reliance on proprietor interpretation and an ad hoc enforcement framework.
Addressed to: Home Office; Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner raised concerns about the insufficient implementation of national recommendations for cardiogenic shock care, including increasing staff awareness and improving out-of-hours echocardiography access. A specific issue was the patient not receiving an echocardiogram before their arrest.
Addressed to: Cambridgeshire and Peterborough ICB; Department for Digital, Culture, Media and Sport; Department of Health and Social Care; Faculty of Intensive Care Medicine; Northamptonshire Children Safeguarding Partnership; North West Anglia NHS Foundation Trust; Royal College of Emergency Medicine; Royal College of Radiology
AI-generated concerns summaryThe NHS Pathways triage tool does not prompt call takers to ask about next of kin or support for individuals unable to move from a sitting position, unlike for those on the floor, potentially risking prolonged immobility.
Addressed to: NHS England; South Central Ambulance Service
AI-generated concerns summaryThe coroner noted significant handover delays at hospitals leading to ambulances being tied up, compounded by emergency department crowding and insufficient social care provision, impeding patient flow and increasing mortality risk.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a risk of unnecessary major operations due to surgical teams lacking full knowledge of disease progression, coupled with an absence of a policy for processing external medical reports. An identified error was also not reported or investigated through the trust's process.
Addressed to: Oxford University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner identified that staff on the NPU lacked knowledge and understanding of the Trust's 'AWOL - Missing & Absent Persons Policy'. This resulted in no individualised assessment for suspending Section 17 leave, and a failure to follow policy regarding staff accompanying police or drafting joint action plans for patient …
Addressed to: South London and Maudsley NHS Foundation Trust