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 that General Practitioners lack a uniform national electronic case management system, leading to delays when records are transferred between practices. This also results in fragmented patient information, stored across both electronic and paper formats.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted unclear reporting structures for falls, inadequate monitoring systems for high-risk residents, and a lack of staff mechanisms to obtain timely medical advice after falls. Insufficient and lost paper records also posed a risk to resident care.
Addressed to: Four Seasons Healthcare
AI-generated concerns summaryThe coroner identified deficiencies in policy management, including relevance, version control, and ensuring staff comprehension. Concerns were also raised about inadequate emergency response training for staff and the quality of adverse incident investigations.
Addressed to: Mandeville Grange Nursing Home
AI-generated concerns summaryThe coroner raised concerns about the excessive delay (up to 18 months) in device examination for individuals released on bail, which prolongs their suicide risk. There was also a lack of proactive support for men less likely to seek help due to shame.
Addressed to: College of Policing; Ministry of Justice; National Police Chiefs’ Council
AI-generated concerns summaryThe coroner raises concerns about the adequacy of communicating suicide risks associated with SSRI medications. Additionally, concerns are noted regarding the appropriateness of guidance for persisting with or switching SSRIs when no benefit or adverse side effects are experienced.
Addressed to: Medicines and Healthcare Products Regulatory Agency; National Institute for Health and Care Excellence; Royal College of General Practitioners
AI-generated concerns summaryThe minimum available insulin prescription quantity was around 10 days of medication, which was large enough to enable an overdose. The coroner noted a smaller amount would have been prescribed if possible to mitigate this risk.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identifies limited availability of naloxone kits for illicit drug users, as access is primarily through substance misuse services that many do not engage with. This risk is heightened by the increased presence of potent synthetic opioids in illicit drugs.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner identified a lack of policy or guidance for Trust staff regarding risk assessment of fixtures and fittings, which acutely mentally unwell patients could use to take their own life.
Addressed to: NHS England; Sussex Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner is concerned that Harbour Healthcare has not instigated an internal investigation into the care provided to Mr Good, despite observations of poor hygiene and infected wounds upon his hospital admission. This investigation is needed to assess risks to other residents and identify learning.
Addressed to: Harbour Healthcare Ltd
AI-generated concerns summaryThe coroner noted the nursing home's limited internal investigation and review process meant there was insufficient reflection on Victor's care, and no clear mechanism for learning lessons from deaths occurring in the home.
Addressed to: Henning Hall Nursing Home; Springcare Care Homes Ltd
AI-generated concerns summaryThe coroner noted a CT scan showing a slipped gastric band was misreported by a radiologist lacking specialist expertise in abdominal imaging. This was attributed to a national knowledge gap among radiologists regarding the presentation of slipped bands, exacerbated by staff shortages and reliance on outsourced services.
Addressed to: NHS England; Royal College of Radiologists
AI-generated concerns summaryThe coroner noted that Mr Crompton was left without anti-epileptic medication for significant periods due to pharmacy supply issues, requiring family members to find alternative supplies. Concerns were raised about the lack of clear designated systems within the pharmaceutical profession to manage medication shortages and ensure patients receive vital medication.
Addressed to: General Pharmaceutical Council; Midway Pharmacy
AI-generated concerns summaryDespite repeated high NEWS scores indicating a need for sepsis six and antibiotics, these were not administered. The hospital software also lacked a digital alert to prompt staff to implement sepsis six.
Addressed to: Royal Cornwall Hospital Trust
AI-generated concerns summarySuspects interviewed voluntarily for offences requiring mental health support do not receive an automatic referral to a mental health nurse, unlike those who are arrested. This means they miss opportunities for assistance from healthcare professionals.
Addressed to: Nottinghamshire Police
AI-generated concerns summaryThe coroner identified that a specific section of the A38 has a higher proportion of road traffic collisions due to its single carriageway layout. A developed safety scheme, incorporating average speed cameras, has not yet been funded.
Addressed to: National Highways
AI-generated concerns summaryThe coroner noted no legal requirement for electric scooter riders to wear helmets, increasing their vulnerability and the risk of death in collisions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner noted significant delays in diagnosis and treatment, including biopsy processing, consultant appointments, and MDT reviews. These delays stemmed from disjointed inter-hospital processes, transport coordination issues, and systemic procedural errors.
Addressed to: Mid and South Essex NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a lack of comprehensive and helpful information for parents on the safe use of baby carriers/slings, particularly when breastfeeding, which poses a suffocation risk to young babies. There is a need for industry standards to promote safe use and warn of risks.
Addressed to: BSI Group; Department of Health and Social Care; NHS England; Office for Product Safety and Standards
AI-generated concerns summaryThe care plan for Mrs. Pye was ambiguous regarding the requirement for two carers, and staff did not consistently follow it. Additionally, there was no system to audit handover documents, and an internal investigation did not highlight these deficiencies.
Addressed to: Care UK Ltd
AI-generated concerns summaryThe coroner noted the lack of availability of specific equipment and adrenaline.
Addressed to: Festimed