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 patient received IV antibiotics correctly under Sepsis 6 guidelines but did not require them. There is an identified tension between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease.
Addressed to: Southmead Hospital
AI-generated concerns summaryThe coroner noted that safety-netting advice provided upon discharge related to headaches, but not to the differential diagnosis of meningitis. The report asks for consideration of safety-netting advice in cases where meningitis has been considered.
Addressed to: University Hospitals Bristol NHS Trust
AI-generated concerns summaryThe coroner noted a lack of national guidance for primary care clinicians on extending anti-coagulation treatment for immobile elderly patients to reduce the risk of deep vein thrombosis in the community.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryMaintaining ketamine's classification as a Class B drug risks encouraging its use under the false impression it is safer than Class A drugs, with users often unaware of the significant long-term health problems it causes.
Addressed to: Home Office
AI-generated concerns summaryThe coroner noted a lack of maintained communication between Huddersfield New College and mental health support organisations (CAMHS, Recovery Steps) regarding Mr Grierson's mental health status and decisions to cease external support.
Addressed to: CAMHS; Huddersfield New College; Recovery Steps
AI-generated concerns summaryThe coroner noted insufficient review of Section 17 leave conditions before unescorted leave, a lack of accessible contact methods for service users on leave, and limitations in the reporting system to identify patient safety issues.
Addressed to: Coventry and Warwickshire Partnership Trust
AI-generated concerns summaryCarers provided insufficient visit times and did not escalate Ms Townend's deteriorating health or inaccurate Early Warning Sign records. Concerns were also raised about the lack of follow-up on her seeking GP support or reassessment of capacity for unwise decisions.
Addressed to: A&B Healthcare Ltd; Care Quality Commission; East Riding of Yorkshire Council
AI-generated concerns summaryThe coroner identified significant deficiencies in a Safeguarding Adult Review, noting that it did not adequately probe responses, failed to record family input, and was conducted hastily without proper documentation or sharing of outcomes and recommendations.
Addressed to: East Riding of Yorkshire Council
AI-generated concerns summaryThe coroner raised concerns about the safety of a narrow, shared path (1.6-2m wide) at a popular location, which is heavily used by both pedestrians and cyclists. This width is significantly below national guidance (3.5m) and allows cyclists to travel at speeds that risk serious injury to pedestrians.
Addressed to: Oxfordshire County Council
AI-generated concerns summaryDelays in information about prescribed medication being sent to GP surgeries by voluntary and NHS organisations were identified.
Addressed to: NHS England & NHS Improvement
AI-generated concerns summaryThe coroner noted that some mental health in-reach staff in the prison over-emphasised a prisoner's wish not to be on suicide watch or ACCT, contrary to policy. Insufficient reassurance was provided that this matter has been addressed.
Addressed to: Barnet, Enfield and Haringey Mental Health NHS Trust
AI-generated concerns summaryUnderestimated pressure sore risk and inadequate pressure area care, including failure to adhere to repositioning schedules, were identified. A wound care plan was not completed, and the post-death investigation did not establish why care gaps occurred.
Addressed to: University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
Addressed to: Department of Health and Social Care; NHS England; The Transformation Directorate
AI-generated concerns summaryThe coroner noted shortcomings in West Midlands Police training and communication protocols, specifically regarding reliance on outdated capacity assessments and not seeking clarification from paramedics when individuals with fluctuating capacity abscond.
Addressed to: West Midlands Police
AI-generated concerns summaryThe coroner identified an insufficient number of mental health beds available at Norfolk and Suffolk NHS Trust to meet patient need, despite actions taken by the trust. This persistent shortage was also noted as a national problem.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a lack of local and national regulation restricting the number and total weight of dogs an individual can walk in a public place, suggesting consideration of such limits for safety.
Addressed to: Home Office; Surrey County Council
AI-generated concerns summaryThe coroner identified gaps in Yorkshire Ambulance Service's 'fit to sit' assessment process, including a lack of documented assessments and an inappropriate decision that an amputee patient was suitable to sit. Concerns also related to the absence of subsequent reassessments and evidence of learning implementation.
Addressed to: Yorkshire Ambulance Service NHS trust
AI-generated concerns summaryThe coroner noted a lack of training for police officers in managing drug concealment in the mouth, including awareness of risks to life for the individual and safety risks for officers when intervening. There is no standard guidance or training provision for officers in drug arrest units for such situations.
Addressed to: College of Policing; Derbyshire Constabulary
AI-generated concerns summaryThe coroner raised concerns that the Medical Priority Dispatch System (MPDS) used for ambulance call prioritisation may no longer be fit for purpose. This is because expected response times for amber 1 calls are not being met due to unforeseen multifactorial issues.
Addressed to: Welsh Ambulance Services University NHS Trust
AI-generated concerns summaryThe coroner noted that the plan of care to reduce the risk of falls for multiple patients was not followed, and there was insufficient reassurance that this risk was being addressed at the time of the inquest.
Addressed to: Barts Health NHS Trust