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 concerns about the choking risk from a thick dental adhesive gel, particularly for older users and those with cognitive decline, as it can be difficult to remove. There is no warning about this hazard on the product packaging or leaflet.
Addressed to: Care Quality Commission; Fixodent
AI-generated concerns summaryThe coroner noted concerns regarding the highly addictive and harmful nature of ketamine, a Class B drug, and the increasing number of young people presenting with potentially fatal health problems linked to its use.
Addressed to: Home Office
AI-generated concerns summaryDoncaster Royal Infirmary has no clear internal policy for disseminating addendum reports or their information from external radiology services to the treating clinical team, risking delays and incorrect patient management.
Addressed to: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that the principle of 'safeguarding is everyone's responsibility' is not fully adopted, risking individual agencies not making referrals if they assume other agencies are aware, potentially hindering a multi-agency approach.
Addressed to: Northumberland Children’s and Adults Safeguarding Partnership
AI-generated concerns summaryConcerns include the misleading 'Physician Associate' title, affecting public understanding and informed consent. The coroner also notes an absence of national and local guidelines for Physician Associate scope of practice and direct supervision, potentially impacting patient safety.
Addressed to: Association of Anaesthetists of GB and Ireland; Care Quality Commission; Department of Health and Social Care; Difficult Airway Society; General Medical Council; NHS England; Royal College of Anaesthetists; Royal College of Emergency Medicine; Royal College of Physicians; Surrey and Sussex Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that the prison's buzzer/intercom system had not worked for several years, and despite a jury finding this to be a failure, the prison or Ministry of Justice still deems it unnecessary, potentially hindering vital communication.
Addressed to: HMP Wormwood Scrubs
AI-generated concerns summaryConcerns relate to SBUHB's practice of often requiring individuals with co-occurring addiction and mental health diagnoses to address addiction before mental health support. Insufficient staff guidance exists for managing these cases and for inter-agency collaboration.
Addressed to: SWANSEA BAY UNIVERSITY HEALTH BOARD
AI-generated concerns summaryCoroner noted insufficient knowledge and judgment among mental health professionals regarding high-risk assessment and Mental Health Act. Concerns also included Mental Health Trust staff's unawareness that A&E policies for risk assessment and monitoring applied.
Addressed to: Care Quality Commission; Department of Health and Social Care; NHS England; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of recorded discussions between Glan Clwyd and the tertiary centre, along with an absence of a formal documented process for inter-hospital referrals, advice provided, and subsequent actions.
Addressed to: Betsi Cadwaladr University Health Board; Ysbyty Gwynedd
AI-generated concerns summaryConcerns included inadequate psychotherapy training on note-keeping, managing suicidality, and responses to at-risk clients. The report also noted insufficient mechanisms for therapist competence and inter-agency care coordination.
Addressed to: British Association for Counselling and Psychotherapy; North London NHS Foundation Trust
AI-generated concerns summaryA patient was not informed of potential malignancy findings from a CT scan, and this information was not followed up or included in her medical history. Additionally, a medical emergency call was not triggered, and doctor review was delayed due to staffing levels.
Addressed to: Mid & South Essex NHS Trust
AI-generated concerns summaryThe Safety at Street Works Code of Practice presents difficulties in calculating distances for roadworks, particularly in darkness or on curved roads without standard street furniture or consistent road markings. The coroner also noted no requirement exists to notify a fatality within roadworks on subsequent permit applications.
Addressed to: Affinity Water; Department for Transport; Essex County Council; Hatton Traffic Management
AI-generated concerns summaryThe coroner raises concerns about the lengthy timescales for applying for and executing Section 135(1) warrants, noting delays due to limited court hearing slots and time taken to schedule police for execution. This creates a risk of harm to individuals awaiting assessment.
Addressed to: Metropolitan Police; Ministry of Justice
AI-generated concerns summaryThe coroner noted concerns regarding the two-week timescale for obtaining and executing Section 135(2) warrants, which creates an ongoing risk of harm to patients during the delay in intervention.
Addressed to: Metropolitan Police; Ministry of Justice
AI-generated concerns summaryThe coroner identified concerns regarding a crisis house's refusal to admit Ms Beavington despite high suicide risk, and the consultant psychiatrist not providing guidance on how to challenge this decision effectively.
Addressed to: North London NHS Foundation Trust
AI-generated concerns summaryPressure ulcer risk assessments are not yet consistently completed in the Emergency Department within the recommended 6-hour timeframe. The ward also experienced periods of insufficient nursing staff for acutely ill patients, with a staffing review ongoing.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryConcerns were raised regarding the insufficient response by medical teams to a deteriorating patient in the Emergency Department resuscitation area and the delay in escalation of care. Staffing levels in this area did not comply with national guidance, and internal investigation recommendations for staffing were not implemented.
Addressed to: NHS England; Royal Stoke University Hospital
AI-generated concerns summaryThe coroner noted prolonged waits in Emergency Departments for high falls risk patients, attributed to a lack of available ward beds due to delayed discharges. There were also unclear national steps for consistent falls risk management in EDs.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryDelays in CT scans following unwitnessed falls and widespread communication issues, including deficient record-keeping, were noted. The coroner also identified staff not following post-fall procedures and a lack of professional curiosity, indicating potential skills or knowledge deficits.
Addressed to: Royal Free London NHS Foundation Trust
AI-generated concerns summaryThe Medical Priority Dispatch System (MPDS) did not allow for an upgrade in ambulance urgency despite evident clinical deterioration and the patient being alone, leading to a prolonged waiting time.
Addressed to: Minister for Health (Wales); Welsh Parliament