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 summaryThe coroner noted a lack of clear guidance between health and social care for discharging patients to care homes, especially when sedated. The patient was discharged to a non-nursing care home while overly sedated, and the discharge letter omitted details of sedation and new oxygen requirements.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a lack of guidelines governing communication and information sharing between private neurodiversity psychiatry providers and NHS services when providing parallel care. This resulted in a patient receiving conflicting advice regarding medication.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted an internal investigation was flawed due to an incorrect report of a witnessed fall. Concerns were also raised regarding the observation of multiple high falls risk patients by a single staff member and a misunderstanding of falls observation terms.
Addressed to: NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST
AI-generated concerns summaryA delay of over 8 minutes occurred before CPR was commenced, indicating a lack of shared understanding among staff regarding the urgency of CPR. There were also unclear protocols defining the respective roles of detention and medical staff during a cell medical emergency.
Addressed to: Leeds Community Healthcare NHS Trust; West Yorkshire Police
AI-generated concerns summaryThe referral to a specialist service lacked adequate information regarding the patient's care needs, the hospital passport was not utilised, and a best interest decision was made without considering the views of long-term carers.
Addressed to: NHS Greater Manchester Integrated Care Partnership Board; Northern Care Alliance NHS Foundation Trust; Oldham Council
AI-generated concerns summaryUnderstaffing in the Royal Free emergency department led to missed hourly observations that could have altered patient management. The coroner also raised concerns about a registrar's practice regarding initial antibiotic administration and their awareness of adult-onset asthma, suggesting training and guideline needs.
Addressed to: Royal College of Emergency Medicine; Royal College of Paediatrics and Child Health; Royal Free Hospital
AI-generated concerns summaryThe coroner noted a lack of confidence among nursing and healthcare staff at St David’s in using falls risk assessments and enhanced supervision documents, identifying a need for more frequent training to prevent future deaths.
Addressed to: Cardiff & Vale University Health Board
AI-generated concerns summaryThe coroner noted failures in updating and documenting care plans and risk assessments, along with inadequate electronic record-keeping. Additional concerns included the non-allocation of a care coordinator and insufficient communication with the family, impacting discharge planning.
Addressed to: Essex Partnership University NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the increased accident risk for inexperienced drivers when carrying young passengers, especially during the initial months after passing their driving test.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of guidance and regulation for children's contact sports, meaning there are no minimum standards for safeguarding, risk management, medical support, or incident planning, particularly for unofficial matches.
Addressed to: Department for Culture, Media and Sport
AI-generated concerns summaryInsufficient funding at University Hospitals Sussex NHS Foundation Trust limits the availability of urgent mechanical thrombectomy services between 4 pm and 8 am.
Addressed to: NHS England; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted untrained support workers were conducting physical health checks with confusion about results and their interpretation, and there was no evidence of training or competency checks for this role.
Addressed to: Revon Healthcare
AI-generated concerns summaryThe coroner expressed concern about the risk to life posed by online suicide forums and social media platforms that provide information on how to take one's own life and advice on misleading others.
Addressed to: Department for Science, Innovation and Technology; OFCOM
AI-generated concerns summaryThe coroner noted non-compliance with Level 2 EICO observation guidelines, as the patient's side room was not within sight or sound of the nursing station. This non-compliance was not escalated to management.
Addressed to: South Tyneside and Sunderland NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a formal process for prisons to share information about a remand prisoner's behaviour and risks with sentencing courts. There is also a lack of national guidance for all prison healthcare providers to ensure continuity of mental health care for prisoners upon release.
Addressed to: College of Policing; HMPPS; National Police Chiefs’ Council; NHS Dorset; NHS England
AI-generated concerns summaryThe coroner raises concerns about probation staff's limited access to specialist medical reports and insufficient training on neurodiverse conditions for frontline staff. Additionally, a loophole exists where court sentences not actioned by probation may not be referred back to court for review.
Addressed to: HMPPS
AI-generated concerns summaryThe coroner identified gaps in pressure sore management, including non-adherence to policies for skin checks and risk assessments, poor documentation, insufficient patient repositioning, and a lack of planned follow-up after specialist assessment.
Addressed to: Royal Devon University Healthcare Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about a national lack of knowledge and guidelines regarding Severe Invasive Soft Tissue Infections, noting that current training is ineffective. Additionally, there is a lack of an audit trail for omitted medication doses in hospitals when medication is unavailable.
Addressed to: NHS England; Royal Stoke University Hospital
AI-generated concerns summaryOfficers at HMP Rochester chairing reviews did not consistently read all relevant documentation, which impacted accurate risk assessment. Furthermore, some officers did not understand how to complete support plan paperwork, leading to ACCTs being closed while support plans were incomplete.
Addressed to: HMP Rochester
AI-generated concerns summaryConcerns were raised regarding inadequate lighting and inconsistent reflective markings on riverside buoyancy aids, hindering their rapid deployment. Additionally, the communication process between the Metropolitan Police Service and the London Fire Brigade relies on a slower telephone system instead of faster electronic transfer, potentially delaying emergency response.
Addressed to: Kingston Council; Lambeth Council; Lewisham Council; London Borough of Barking and Dagenham; London Borough of Bexley; London Borough of Hammersmith & Fulham; London Borough of Havering; London Borough of Richmond upon Thames; London Fire Brigade (LFB); National Fire Chiefs Council; Newham Council; Royal Borough of Greenwich; Royal Borough of Kensington & Chelsea; Southwark Council; City of London; Tower Hamlets Council; Wandsworth Borough Council; Westminster City Council