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 ambulance response times for Category 1 and 2 calls remain outside target standards, and the 15-minute hospital handover target is not being achieved, impacting ambulance availability in the community.
Addressed to: NHS England; West Yorkshire Integrated Care Board
AI-generated concerns summaryThe coroner noted a significant delay in Mr Curry's urgent surgery due to a lack of theatre capacity, which resulted in a prolonged stent dwell time and an increased risk of post-operative urinary infection and sepsis.
Addressed to: Secretary of State for Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns that excessively long waiting lists for heart treatment pose a national problem, as a patient's prolonged wait for treatment led to complications from long-term steroid use.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe Trust made no progress on a recommended Standard Operating Procedure for four years. Concerns were raised that CT scanning for suprapubic catheter insertion was suboptimal compared to ultrasound, with no ultrasound training provided to consultants.
Addressed to: East Lancashire Hospitals Trust
AI-generated concerns summaryConcerns were raised after a care home resident was administered toxic and fatal quantities of medication by staff, with the cause of this administration remaining unascertained, creating a risk of recurrence.
Addressed to: Voyage Care Cloverdale
AI-generated concerns summaryThe patient safety investigation report was delayed and lacked comprehensive detail on anticoagulant omissions and issues with capacity assessments and best interests decisions across hospital settings. Related training was also limited.
Addressed to: County Durham and Darlington NHS Foundation Trust
AI-generated concerns summaryThere is open access from the carpark at The Treetops Apartment complex to a wooded area, lacking a barrier to an adjacent pathway and warning signage for a dangerous drop. No changes have been made since the incident, meaning the risk remains.
Addressed to: Seascape Homes and Property Limited
AI-generated concerns summaryThe coroner notes two legislative issues regarding publications instructing on ending life: the Suicide Act penalty does not apply to companies, and the Online Safety Act does not cover products directly sold by Amazon UK.
Addressed to: Department for Science, Innovation & Technology
AI-generated concerns summaryThe coroner identified a lack of night-time healthcare provision and guidance for prison staff assessing prisoners under the influence of substances. Also noted were inconsistencies in policy and practice for sharing essential medication information between healthcare and prison staff.
Addressed to: HMP Rochester; Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner noted insufficient escalation of a prisoner's refusal of food and fluids, leading to inadequate monitoring. Concerns were also raised regarding the general lack of a formal policy to monitor meal collection in prisons, identifying a risk in other establishments.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner noted a lack of prompt action and a culture within the midwifery team of not responding urgently to antepartum haemorrhage, often assuming a benign cause rather than following established Trust guidance.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of a single reference point for clinicians to quickly identify medications with side-effects increasing suicidal behaviour. Concerns were also raised about limited recording of telephone calls at Norfolk and Suffolk Foundation Trust, impacting patient safety, and delays in patients accessing mental health services for medication …
Addressed to: Department of Health and Social Care
AI-generated concerns summaryPoor communication between the domiciliary care company, local authority, and NHS trust meant Mr Ahmed's deteriorating health and living conditions were not identified. Additionally, his poor decision-making regarding budgeting and heating, and his refusal of personal care, went unchallenged by carers.
Addressed to: Department of Health and Social Care; East London Foundation NHS Trust; London Borough of Newham; Sunlight Care Group
AI-generated concerns summaryThe coroner raises concerns about the lack of widespread endorsement and dissemination of PUMA guidelines, which state capnography is the mainstay for confirming tracheal tube placement. It is also noted that unrecognised oesophageal intubation is no longer a 'Never Event' by NHS England, despite prior PFD reports on this issue …
Addressed to: Faculty of Intensive Care Medicine; NHS England; Royal College of Anaesthetists; Royal College of Emergency Medicine
AI-generated concerns summaryBed rails were routinely erected before a Falls Assessment, contrary to policy, and procedures to establish whether a call bell is working were unsatisfactory.
Addressed to: Hereford County Hospital
AI-generated concerns summaryThe coroner is concerned about the quality, effectiveness, and timeliness of the Health Board's investigations, which may delay identifying care issues and implementing measures to prevent future deaths.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted widespread poor record keeping, including unrecorded calls and inadequate handovers. Concerns were also raised regarding the poor quality and falsification of observation records, and the ineffectiveness of existing auditing processes.
Addressed to: East London Foundation Trust (ELFT)
AI-generated concerns summaryThe coroner noted a lack of clear images within guidance materials produced by the HSE to assist drivers in safely loading and unloading bales.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner noted concerns regarding a potential increased incidence of certain blood cancers in patients taking Clozapine, citing small international studies. Further research is needed to confirm or refute whether Clozapine materially increases this risk.
Addressed to: Britannia Pharmaceutical Ltd; Leyden Delta Ltd; National Institute for Health and Care Excellence; Viatris UK Healthcare Ltd
AI-generated concerns summaryThe coroner identified a lack of accountability for staff not adhering to health board policies, which potentially perpetuates future patient risk. Concerns also related to the failure to implement identified learning and actions in a timely manner, leaving risks unmitigated.
Addressed to: Betsi Cadwaladr University Health Board