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 a concern that no system currently allows clinicians in the Emergency Department to easily access records made by colleagues working on the Virtual Ward.
Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that public safety signs regarding water hazards such as undercurrents and rip-tides were not prominently displayed compared to administrative signs. This could lead people to misinterpret or underestimate the dangers of entering the water, especially out of season.
Addressed to: Sedgemoor District Council
AI-generated concerns summaryThe coroner noted that the footbridge from which the deceased fell was not selected for barrier height increases, unlike other local bridges, leading to concerns about the continued risk of falls from this bridge onto the motorway.
Addressed to: National Highways; Salford City Council
AI-generated concerns summaryDiffering definitions of patient 'stability' between the Home Treatment Team and talking therapies service created a barrier to accessing care. The coroner also noted insufficient evidence that updated referral processes within the HTT had been embedded or audited.
Addressed to: Pennine Care NHS Trust
AI-generated concerns summaryThe coroner noted insufficient weight given to collateral information during mental health triage, resulting in untimely referrals for treatment. Concerns were also raised about out-of-hours information sharing gaps between police, mental health agencies, and adult safeguarding.
Addressed to: Surrey and Borders Partnership; Surrey County Council; Surrey Police
AI-generated concerns summaryExtensive delays in contacting a patient for an urgent gynaecology appointment were noted, due to reliance on written correspondence. Re-referrals did not adequately consider previous delays, resulting in a 24-month delay to diagnosis.
Addressed to: Cwm Taf Morgannwg University Health Board
AI-generated concerns summaryThe UKHSA's information gathering regarding the E coli source was incomplete, and crucial details from the family were not sought. Public health authorities also did not provide adequate safety advice to the family or feedback to treating clinicians, making it difficult for the family to obtain information.
Addressed to: UK Health Security Agency; University College London Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about inaccurate care home records regarding a resident's diet, noting that details from other residents' files were incorrectly copied, leading to a risk of further deaths.
Addressed to: HADDON COURT REST HOME, BLACKPOOL
AI-generated concerns summaryThe coroner noted a lack of awareness regarding adequate support for mattress extensions on nursing care beds, posing a risk of entrapment. Concerns were also raised that briefings for staff on checking residents in distress at night are not formalized into policy or procedure.
Addressed to: Care Quality Commission; Medicines and Healthcare Products Regulatory Agency; Red House (Ashtead) Limited
AI-generated concerns summaryThe coroner noted a lack of adequate crisis support systems for patients over 65, as the crisis service was unavailable to them despite being accessible to those 65 or under. GP surgeries and police also incorrectly directed or halted referrals based on age.
Addressed to: Rotherham, Doncaster and South Humber NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that SECAMB has not provided evidence that its timeline for clinical validation of Category 3 and 4 ambulance calls is being met, raising concerns that late re-triage or validation places patients at risk.
Addressed to: South East Coast Ambulance Service
AI-generated concerns summaryThe coroner raised concerns that neurology patient notes were stored on a separate 'patient pass' system, which lacked detail and was not easily accessible. This led to disjointed care and communication gaps within the neurology service and with other clinicians.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryConcerns were raised that standard competence-based training for Mobile Elevated Working Platforms (MEWPs) operators, including IPAF certification, lacks practical 'at height' or 'basket to basket' rescue drills, which are crucial for rapid response.
Addressed to: Independent Training Standards Scheme and Register; LANTRA; National Open College Network as part of the Construction Plant Competence Construction Scheme; National Plant Operators Scheme; International Powered Access Federation; Road Transport Industry Training Board
AI-generated concerns summaryThe coroner identified a hazard on Lee Lane where a road crest can cause vehicles to lose control or bottom out at speeds within the limit, exacerbated by poor visibility beyond the crest and a lack of warning signs.
Addressed to: Hampshire County Council
AI-generated concerns summaryThe coroner raised concerns that the police force's understanding, training, and procedures for responding to automated crash detection calls from electronic devices require review to ensure a prompt response in situations indicating a collision with a risk to life.
Addressed to: Hampshire Constabulary; National Police Chiefs’ Council
AI-generated concerns summaryThe Essex Partnership University NHS Foundation Trust's local guidance allows a 7-day response for mental health crisis category D, deviating from the national 72-hour standard. Its operational policy also incorrectly states triage codes D and E as 'within 24 hours', conflicting with national guidance.
Addressed to: ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
AI-generated concerns summaryThe coroner noted insufficient completion of nutrition and fluid documentation, including MUST charts, leading to inadequate monitoring of Mr Astley's intake. Overall documentation at the care home also lacked detail.
Addressed to: Care Quality Commission; Downshaw Lodge
AI-generated concerns summaryEmergency cell bells at HMP Forest Bank can be readily deactivated by other prisoners, meaning the detection of medical emergencies is dependent on chance rather than robust systems, which poses a risk of future deaths.
Addressed to: HM Prison and Probation Service; Ministry of Justice
AI-generated concerns summaryThe coroner identified a lack of effective hospital systems to prevent a patient from receiving double the maximum medication dose for six months. Concerns were also raised about inadequate searches and record-keeping after a patient's unescorted leave, along with the overall security arrangements.
Addressed to: In Mind Healthcare Group Ltd; Waterloo Manor Hospital
AI-generated concerns summaryThe coroner noted a patient spent 22 hours in an A&E corridor due to capacity issues, which was a widespread problem. Additionally, the care home lacked robust systems to monitor the patient's nutritional status and fluid intake.
Addressed to: Care Quality Commission; Department of Health and Social Care; Lakes Care Centre