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 a lack of emergency department beds, leading to long waits and patients having poor experiences, which can deter return for care. This issue, often due to beds being blocked by medically fit patients, contributes to delays that increase the risk of future deaths.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the lack of inpatient psychiatric beds, leading to unacceptable wait times in A&E for mental health patients. The A&E environment was noted as unsuitable for those awaiting mental health beds, especially individuals with Autism or who are neurodiverse, as it can exacerbate their condition.
Addressed to: NHS England & NHS Improvement; NHS Sussex Integrated Care Board
AI-generated concerns summaryThe coroner noted a disparity in monitoring and discussion of Clozapine side effects for patients attending GP practices compared to specialist clinics, highlighting this as a potential national issue. There was also insufficient focus on cardiomyopathies like left ventricular hypertrophy in Clozapine guidance, which is based on national recommendations.
Addressed to: Devon ICB; Devon Partnership NHS Trust; Medicines and Healthcare Projects; Pembroke Medical Practice
AI-generated concerns summaryThe coroner identified a need for a real-time database of hospital helicopter landing sites and contact details for site managers to ensure safe helicopter landings.
Addressed to: Department for Transport; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that Circle Healthgroup Ltd hospitals have no plans to introduce an electronic system for recording patient observations. This raises a risk by limiting accurate timing records, trend analysis for deteriorating patients, and the reduction of errors from manual recording.
Addressed to: Circle Health Group Ltd
AI-generated concerns summaryThe coroner noted that the design of the telephone hood provided a means for Mr Jones to take his life, and the Metropolitan Police Service (MPS) had insufficient oversight of the public reception area.
Addressed to: Metropolitan Police Service (MPS)
AI-generated concerns summaryThe moto-cross track lacked meaningful rider registration, safety briefings, and adequate marshalling with first aid trained staff. The coroner noted an absence of mandatory regulation and minimum safety standards for such venues.
Addressed to: Department for Culture, Media and Sport; Department of Transport
AI-generated concerns summaryThe coroner noted delays in 999 calls connecting to an Emergency Call Taker and prolonged ambulance response times. There is a particular focus on improving the system for connecting calls to an ECT, including defaulting to other ambulance services.
Addressed to: South Central Ambulance Service
AI-generated concerns summaryThe coroner noted significant delays in ambulance allocation, caused by extensive handover delays from ambulance crews to acute hospitals, resulting in substantial lost ambulance time. These delays in ambulance service provision are continuing.
Addressed to: South Western Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in statutory swimming lesson provision, with some schools not delivering them. Concerns were also raised that new signs at Scotsmans Flash do not explicitly prohibit swimming, and proposed life-saving equipment will not be placed at optimal entry points.
Addressed to: Wigan Metropolitan Borough Council
AI-generated concerns summaryA patient at very high risk of pressure ulcer development was not repositioned according to her care plan for many hours on multiple days, despite repeated advice. The Trust's post-death investigation did not provide a satisfactory explanation for this non-adherence.
Addressed to: Somerset NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that petrol stations do not ensure compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014, particularly regarding restrictions on who can dispense petrol. It was noted that current guidance for petrol stations does not ensure compliance with these regulations.
Addressed to: Association for Petroleum and Explosives Administration; Department for Work and Pensions; Energy Institute; Petroleum Enforcement Liaison Group
AI-generated concerns summaryThe coroner noted that Jean's fluid balance was not monitored by either nursing or medical staff, despite her complex cardiovascular and renal conditions requiring this essential care.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner raised concerns about the lack of documented assessments following unescorted leave for patients with a propensity to ingest vegetation, alongside staff confusion regarding assessment procedures and documentation requirements.
Addressed to: Elysium Healthcare
AI-generated concerns summaryConcerns include the absence of a formal mental health assessment at discharge for veterans, a lack of inquiry into drug use correlation with PTSD, and insufficient long-term rehabilitation for veterans with PTSD and substance abuse issues.
Addressed to: Ministry of Defence
AI-generated concerns summaryThe coroner identified increased risks associated with inexperienced drivers, especially when carrying young passengers, which can lead to loss of control. A Graduated Driving Licence Scheme was suggested to mitigate these risks by imposing temporary restrictions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a need to review the online prescription service, noting its limited access to patient records and lack of features for prescribers to add comments or screen for suicidal ideation. The report also highlights the potential to limit prescription quantities for certain medicines.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe Urgent Care and Assessment Team declined a referral for a patient who expressed an intent to take his own life, and no record was kept of the referral or the identity of the person who made the decision.
Addressed to: Northamptonshire Healthcare Foundation Trust
AI-generated concerns summaryAmbulance delays are significantly contributed to by hospital handover delays, exacerbated by a backlog of patients awaiting social care packages, which reduces overall ambulance availability.
Addressed to: Department of Health and Social Care; NHS England & NHS Improvement; The Chief Coroner
AI-generated concerns summaryThe coroner identified a lack of training for university wellbeing services on Emotionally Unstable Personality Disorder. Concerns also included staff unawareness of direct mental health team transfers, insufficient responsible clinician involvement in discharge planning, and the absence of a proactive policy for seeking patient consent to share information.
Addressed to: Arts University Bournemouth; Devon Partnership NHS Trust; Dorset Healthcare NHS Foundation Trust