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 insufficient community-based support for individuals with dementia, which meant families could not continue home care and necessitated moves to unfamiliar care home environments.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted a discrepancy in evidence regarding systems for checking residents after fire alarm activations, raising concerns that new processes have not been effectively communicated to care staff. Further training and clear protocols for staff response to fire alarms are needed.
Addressed to: National Care Consortium Ltd; Pristine Care Group Ltd
AI-generated concerns summaryThe coroner noted that the carpark's speed bumps have been identified as the cause of multiple falls.
Addressed to: Staffordshire Moorlands District Council
AI-generated concerns summaryThe coroner raised concerns regarding the ineffective verbal handover process between ambulance and A&E, compounded by incompatible IT systems and high acuity. There is a lack of national protocols or guidance for patient handovers at Accident and Emergency units, including for confirming the handover of basic observations.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified issues with skin integrity risk assessment and monitoring, incomplete repositioning records, and a lack of management oversight regarding care plan compliance and staff training in these areas.
Addressed to: Happy at Home Community Care Services Ltd
AI-generated concerns summaryThe coroner noted the absence of road markings or signs to advise on speed or road curvature on a slip road where a collision occurred, raising concerns about the safety of road conditions at that location.
Addressed to: National Highways
AI-generated concerns summaryInadequate recording of oral instructions and insufficient verification by the prescribing anaesthetist created unclear responsibility for checking and administering local anaesthetic. Inconsistent prescription of local anaesthetic (ml vs mg) was also identified as a risk.
Addressed to: Royal College of Anaesthetists
AI-generated concerns summaryConcerns relate to Neonatology Consultants not being immediately on-site overnight or weekends and covering two distant hospital sites. The coroner identified that this arrangement may result in variable attendance times, which poses a risk of future deaths.
Addressed to: British Association of Perinatal Medicine; NHS England; University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted liquid food in Mr Clark's airway despite a nil-by-mouth order, and an NG tube was removed and lost before autopsy, impeding investigation. This raised concerns about the Trust's ability to secure and review evidence, particularly as its own review overlooked the tube's removal.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns that the STREAMing guidance, by prioritising current cardiac-sounding chest pain, may delay the diagnosis of other immediately life-threatening conditions or risks of sudden deterioration, affecting both cardiac and non-cardiac patients.
Addressed to: National Institute for Health and Care Excellence; NHS England; Royal College of Emergency Medicine
AI-generated concerns summaryThe coroner noted that the deceased's family had contacted the council about a hazardous broken pavement, but no action was taken to repair it prior to her death.
Addressed to: Milton Keynes City Council
AI-generated concerns summaryThe coroner raised concerns regarding the design of the Jaguar i-Pace gear selector, noting that the absence of an intermediary step, such as a lever in addition to a button press, may have contributed to a driver's errors in selecting the wrong gear.
Addressed to: Jaguar Land Rover
AI-generated concerns summaryThe coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department congestion, over-reliance on the NEWS algorithm, and insufficient clinical curiosity.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryDespite remedial measures, drivers continued to turn the wrong way down a slip road. Investigations indicated that verbal commands from commonly used satnav applications were confusing and misdirecting drivers into oncoming traffic.
Addressed to: Apple UK Limited; Google; National Highways; TomTom
AI-generated concerns summaryThe GP practice lacked a system for tracking and triaging email queries, and there were no robust processes for checking patient contacts or maintaining an audit trail for electronic referrals.
Addressed to: Department of Health and Social Care; SSP Health
AI-generated concerns summaryThe coroner noted concerns regarding the handling of a patient's complaints form, which contained a significant "note of intent." This process meant crucial information was not read by staff, delaying its disclosure to investigations and the family, and risking missed opportunities for intervention.
Addressed to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of recognition in primary care that the patient's learning disability affected their engagement, with no doctor attempts to speak to the patient and no involvement from the learning disability team.
Addressed to: Greater Manchester Integrated Care Partnership
AI-generated concerns summaryThe coroner noted a lack of consideration for managing anaphylaxis risk during journeys to and from school. There was no appropriate structure to educate schools, patients, and parents on the importance of carrying adrenaline auto-injectors during these times.
Addressed to: Department for Education; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted dental staff did not recognise excessive salivation as anaphylaxis, and allergy plans listing lip swelling as mild risked false reassurance. There is a need for clearer guidance differentiating anaphylactic from mild reactions and for enhanced patient education on adrenaline auto-injector use.
Addressed to: British Society for Allergy and Clinical Immunology; General Dental Council; NHS England; Pharmaceutical Council; Royal College of Paediatrics; Royal College of Physicians
AI-generated concerns summaryConcerns were raised regarding an incorrect NEWS score calculation by a nurse, which led to a failure to refer the patient to a senior medical practitioner. Additionally, subsequent observations were not performed in line with NEWS requirements.
Addressed to: Aneurin Bevan University Health Board