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 staff were not explicitly taught to escalate 'no observations' due to patient distress as urgently as worrying observations. Additionally, the electronic patient record system did not track repeat presentations for the same illness within the emergency department.
Addressed to: Royal College of Emergency Medicine; Royal College of Paediatrics and Child Health; Royal Free Hospital
AI-generated concerns summaryThe In-Patient Medication Administration Record lacks a recorded prescription time, making it difficult to verify timely administration. Additionally, the Accident & Emergency Record Card has no provision for recording medication prescription and administration details.
Addressed to: Hywel Dda University Local Health Board; NHS Wales
AI-generated concerns summaryThe coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational support group officers lacked or did not follow essential training.
Addressed to: HMP Swaleside; Ministry of Justice
AI-generated concerns summaryOutstanding actions from a Structured Judgement Review, including the review of patient records not seen in over 12 months and clinical caseload stratification, are noted. The absence of a scheduled audit date for these processes raises concerns about future deaths.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner identified gaps in the timely completion and staff awareness of Datix reports. Concerns were also raised regarding automated approval processes for these reports and the use of templates, potentially leading to incomplete incident information.
Addressed to: University Hospitals Birmingham
AI-generated concerns summaryThe coroner noted that the pharmacist provided controlled drugs in advance, not strictly adhering to supervised prescription terms, which resulted in the deceased possessing multiple doses. The drug treatment provider was not informed of this practice, preventing their risk management of the prescribing arrangements.
Addressed to: General Pharmaceutical Council; York Road Pharmacy
AI-generated concerns summaryThe coroner noted inconsistent compliance in informing carers of Section 17 leave terms and providing the relevant forms. A policy change also removed the requirement for accompanying persons to sign the Section 17 leave form, which could increase future risk.
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of an effective system to document and address the risk of elderly patients falling while in the hospital, specifically an omission in recording a one-to-one supervision plan in medical records.
Addressed to: North Middlesex University Hospital NHS Trust
AI-generated concerns summaryThe coroner identified concerns that the national speed limit on a rural, unlit section of the A518 at Blythe Bridge is too high for the road's characteristics, including a sharp bend, contributing to a risk of future collisions.
Addressed to: Staffordshire County Council
AI-generated concerns summaryThe coroner identified concerns regarding the rigidity and lack of flexibility in aftercare criteria for individuals detained under the Mental Health Act where Section 117 does not apply, noting this can lead to unsuitable accommodation and a risk of future deaths. It was suggested decision makers be given greater discretion …
Addressed to: Ministry of Housing, Communities and Local Government
AI-generated concerns summaryThe coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the awareness and use of Steroid Emergency Cards, and GPs not routinely using the option to place alerts on ambulance systems …
Addressed to: Association of Ambulance Chief Executives; NHS England; North East Ambulance Service NHS Foundation Trust; Royal College of General Practitioners
AI-generated concerns summaryThe coroner identifies that laundry tablets and their bright, sweet-like packaging can be confused with food by individuals with dementia or cognitive impairment, leading to accidental ingestion. Additionally, the packaging lacks features to make accessing the contents difficult.
Addressed to: Department of Health and Social Care; Office for Product Safety and Standards; Sainsburys; UK Cleaning Product Industry Association
AI-generated concerns summaryThe coroner noted a lack of national guidance on recommencing anticoagulation after a head injury and no recommendation for clinicians to discuss associated risks and benefits with patients.
Addressed to: National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThe coroner noted an inadequate review and incident investigation following Mr Lyalushko’s death, which failed to identify an un-actioned GP request, incorrectly assessed areas for improvement, and did not involve family consultation.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the unavailability of beds for individuals requiring compulsory detention under the Mental Health Act, leading to a patient not receiving an admission that was considered highly likely to have prevented their subsequent actions.
Addressed to: NHS England
AI-generated concerns summaryThe coroner was concerned that the planning for safe staffing levels during junior doctor strikes was insufficient, leading to a patient receiving no medical input and creating a risk of future deaths.
Addressed to: North Cumbria Integrated Care NHS Trust
AI-generated concerns summaryConcerns relate to insufficient understanding of coercive control among frontline police, the DOM5 risk assessment form's lack of clarity on psychological harm, and Thames Valley Police not adopting a new domestic abuse risk assessment tool.
Addressed to: National Police Chiefs’ Council; Thames Valley Police
AI-generated concerns summaryBreaches of probation terms by an individual known to be dangerous to females, alongside insufficient monitoring of sex offenders in the community, were noted. The coroner identified a need for improved information sharing between police and probation services.
Addressed to: HM Prison and Probation Service; Thames Valley Police
AI-generated concerns summaryThe coroner noted significant delays in recognising a patient's unresponsiveness and calling an emergency ambulance, as staff did not activate the rapid response system and awaited doctor approval. Concerns were raised that conflicting staff understanding of emergency call protocols persists, leaving a risk of recurrence.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted gaps in discharge planning at Priory Dorking, including no safety plan or 48-hour follow-up. Concerns also included a lack of communication between Priory sites and with NHS services, and insufficient internal reviews at both locations.
Addressed to: NHS Greater Manchester Integrated Care Board; Pennine Care NHS Foundation Trust; Priory Group