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 that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for escalating mental health problems.
Addressed to: British Airline Pilots’ Association; Civil Aviation Authority
Addressed to: Bradford District Care NHS Trust
AI-generated concerns summaryThe coroner noted concerns regarding the absence of adequate street lighting and appropriate traffic warning signs on Dryden Street, Bradford, which likely contributed to the incident.
Addressed to: Bradford Council
AI-generated concerns summaryPoor street lighting obscured a 90-degree turn and wall at the end of Dryden Street, and there were no warning road signs to alert drivers to the turn or dead end. These factors likely contributed to the fatal accident.
Addressed to: Bradford Council
AI-generated concerns summaryConcerns were raised that a patient was discharged from Ward F without multi-disciplinary meetings with community professionals who had expressed significant safety concerns. The health board's internal investigation did not identify this lack of consultation, indicating a potential ongoing risk from insufficient multi-disciplinary decision-making.
Addressed to: Swansea Bay University Health Board
AI-generated concerns summaryA patient was discharged rather than referred for surgical review. The coroner noted the lack of a definitive timescale for implementing a "Failed Discharge" policy to streamline specialist referrals for patients re-attending the Emergency Department.
Addressed to: Cwm Taf Morgannwg University Health Board
AI-generated concerns summaryThe coroner noted that the care home did not ensure a resident received prescribed antibiotics or further medical care in a timely manner, and lacked documented evidence of system improvements to prevent similar issues for other residents.
Addressed to: Abbey Place Nursing Home
AI-generated concerns summaryThe coroner raises concerns about the lack of installation of door top alarms on patient bedroom doors at Sherbourne Ward, a known high-risk ligature point. Despite being identified as a mitigation, these environmental changes have not been implemented after 42 months.
Addressed to: Coventry and Warwickshire Partnership NHS Trust
AI-generated concerns summaryClinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.
Addressed to: Care Quality Commission; Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted concerns that the ambulance crew did not recognise the patient's deteriorating cardiogenic shock symptoms, leading to an incorrect categorisation of the backup request and a delay in receiving the highest priority paramedic assistance.
Addressed to: Nerams Group
AI-generated concerns summaryThe coroner notes that the dangers of combining amitriptyline, paroxetine, and ivabradine are not widely appreciated and do not trigger prescribing software alerts, and prescribers may lack full understanding of these interactions.
Addressed to: National Institute for Health and Care Excellence; Royal College of Physicians
AI-generated concerns summaryThe coroner raises concerns about the lack of guidance for officers when managing individuals suspected of swallowing drugs during a stop and search who are not arrested, particularly regarding powers to convey them to hospital and the advice provided upon release.
Addressed to: College of Policing; National Police Chiefs’ Council
AI-generated concerns summaryGaps were identified in the quality of internal investigations, particularly concerning medication monitoring and verifying details of CPN visits. The report also notes barriers to appropriate Mental Health Act assessments, insufficient information sharing between agencies, and a need for more focused mental health training for support workers.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust; Birmingham City Council; Provident Housing
AI-generated concerns summaryThe coroner raised concerns regarding the length of time it took for Greater Manchester Police to recognise Mr Lawless’s death as a 'Death or Serious Injury' under the Police Reform Act 2002.
Addressed to: Greater Manchester Police
AI-generated concerns summaryThe coroner noted a continuing risk that care staff may not recognise and take appropriate action for serious acute mental health issues, citing examples of inaccurate record-keeping and a care co-ordinator not actioning a GP's request for written concerns.
Addressed to: All Care In One Ltd
AI-generated concerns summaryThe coroner was unable to secure information or medical records from the Turkish hospital regarding the patient's fitness for surgery and the specific details of the procedure performed.
Addressed to: Department of Health and Social Care
AI-generated concerns summarySignificant delays in ambulance response times were observed, directly attributable to prolonged patient handover times at Royal Cornwall Hospital, resulting in substantial lost ambulance hours.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in information sharing between the ambulance service and police, leading to ambulance delays, incomplete patient information, and police not being informed of likely response times. This prevented officers from considering alternative transport options for the individual.
Addressed to: Devon and Cornwall Constabulary; South Western Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe Royal Shrewsbury Hospital lacks written records for explaining potential side-effects and complications of new prescribed drugs to patients, including what to do and where to get help. There is also no provision to record what happens when a patient lacks capacity to understand these explanations.
Addressed to: NHS England; Shrewsbury and Telford NHS Trust
AI-generated concerns summaryThe coroner identified concerns regarding inaccurate care home records not reflecting a patient's deterioration, the failure to update the falls risk assessment after a fall, and an inadequate post-falls investigation.
Addressed to: Willow Grange Care Home