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 gaps in the GP surgery's call handling process, noting a lack of clear pathways and triage tools for administrative staff to recognise urgent medical needs and ensure appropriate clinical referral, such as for suspected allergic reactions.
Addressed to: ASHTON MEDICAL PRACTICE; SSP HEALTH; WIGAN INTERGRATED CARE BOARD
AI-generated concerns summaryBedford Hospital had not adopted national safety observations from 2022 regarding paracetamol dosing for low-bodyweight patients. The electronic system lacks alerts for weight accuracy in paracetamol prescriptions, and practical steps for routine patient weighing are insufficient.
Addressed to: Bedford Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of investigation into care concerns raised by clinicians in August 2023, and that the Trust did not follow its own recommendation for a detailed investigation, leaving potential system issues unresolved.
Addressed to: Northampton General Hospital
AI-generated concerns summaryThe coroner noted that current careline protocols, including those of the Telecare Services Association, may not adequately support users with communication impairments, potentially leading to missed opportunities for vital medical assistance. More time and specific questioning methods could elicit crucial information.
Addressed to: Telecare Services Association
AI-generated concerns summaryThe coroner noted that the NHS Pathways system has limited mental health triage options and declined to make changes. This led to serious mental health crisis situations being inadequately categorized and experiencing significant delays in ambulance attendance.
Addressed to: NHS Pathways
AI-generated concerns summaryThe coroner noted that the hospital's investigation incorrectly concluded the incident was unforeseen. The patient involved had a history of aggressive behaviour, and there was a need for enhanced observations which, if implemented, could have prevented the incident.
Addressed to: University Hospitals Plymouth NHS Trust
AI-generated concerns summaryConcerns were raised about delays in administering Naloxone due to frequent stock shortages, and a lack of awareness regarding opioid toxicity risks in patients with kidney impairment.
Addressed to: Royal Free Hospital
AI-generated concerns summaryUnsuitable housing lacked a key safe for emergency access, and an inappropriate reablement package was provided for cognitive decline. A fall was not escalated, and cognitive impairment was not fully considered upon community service discharge.
Addressed to: Daryel Care; Islington Council; Whittington Health
AI-generated concerns summaryThe coroner noted a multi-factorial delay in the patient receiving prompt, necessary treatment despite their life-threatening condition being immediately recognised. There is a need for national sharing of learning from such incidents to benefit patients elsewhere.
Addressed to: Homerton University Hospital NHS Trust
AI-generated concerns summaryThe coroner noted that the GP practice failed to conduct a significant event review or implement agreed learning regarding the communication of abnormal test results to secondary services. This indicates an insufficient system for learning from events, which could impact future patient outcomes.
Addressed to: Attleborough Surgery
AI-generated concerns summaryThe coroner noted insufficient assertive engagement by the enhanced community mental health team and a lack of liaison between police and the mental health team regarding Claire's deteriorating mental health. Additionally, training on substance misuse for mental health staff is not mandatory.
Addressed to: South West Yorkshire Partnership NHS Foundation Trust
AI-generated concerns summaryConcerns were raised about the inadequate recording and transmission of information regarding Mr Omishore's mental state from police call handlers to responding officers. This prevented officers from considering this critical information before arriving at the scene.
Addressed to: College of Policing; Metropolitan Police
AI-generated concerns summaryThe coroner noted that the HSE website's guidance for volunteers does not sufficiently emphasize the importance of written risk assessments and method statements for construction work. Concerns were also raised about the comprehensiveness of the volunteering section and the need to remind organisations to seek professional advice.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe Trust lacked a specific Ryles tube policy, leading to inadequate guidance for clinicians and missing records of repeat position checks. Furthermore, a narrowly focused review of the death overlooked critical issues like missing clinical observations and Ryles tube checks.
Addressed to: Oxford University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns that many non-gastro specialist clinicians in NHS England are unaware of the critical difference between hiatus hernia types, which is not distinguished in NHS England guidance. This lack of awareness means no increased vigilance for patients with the higher-risk para-oesophageal hiatus hernia.
Addressed to: Department of Health and Social Care; British Society of Gastroenterology
AI-generated concerns summaryThe coroner noted a lack of available British Sign Language interpreters for Deaf mental health patients, particularly when urgent assessments were required in a crisis. This also caused delays to the inquest proceedings.
Addressed to: Department of Health and Social Care; National Register of Communication Professionals working with Deaf and Deafblind people (NRCPD); NHS England
AI-generated concerns summaryThe coroner noted a persistent lack of candour within the Trust, impacting safety and learning, alongside deficient and chaotic clinical governance arrangements. These included untrained staff, poor document control, and issues with data reliability.
Addressed to: Department of Health and Social Care; NHS England; NHS Lancashire and South Cumbria Integrated Care Board; University Hospitals of Morecambe Bay NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that different mental health teams used incompatible computer systems, leading to incomplete information for suicide risk assessments. Additionally, staff training needs regarding proper risk assessments were not being addressed.
Addressed to: Crisis Resolution Team; Midlands Partnership Foundation Trust; Stoke Talking Therapies
AI-generated concerns summaryThe coroner noted insufficient awareness of the Perinatal Mental Health Service among health professionals and inadequate staffing of perinatal health visitors. Additionally, the Single Point of Access meetings lacked written records of discussions and decisions, impacting patient care.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted insufficient guidance for clinicians on managing abnormal antenatal CTG results, specifically lacking protocols on if and when delivery should occur. This means decision-making depends solely on individual clinical judgment.
Addressed to: National Institute for Health and Care Excellence; Royal College of Obstetricians and Gynaecologists