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 frequent ward moves for Mrs Spedding, which resulted in breaks in her continuity of care, and raised concerns about the hospital's increasing reliance on 'escalation beds' due to bed pressures.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified that doctors at Macclesfield Hospital could not access GP records for patients registered outside the trust's area, which limited their understanding of patient history. This issue, attributed to differing NHS IT systems, was noted to cause difficulties in providing effective and timely care.
Addressed to: East Cheshire NHS Trust; NHS England
AI-generated concerns summaryThe coroner identified inadequate and insufficiently advanced warning signs for a flood-prone unbridged Ford, particularly their visibility during extreme flooding. Concerns were also raised regarding the insufficiency of temporary road closure signs and delays in implementing more permanent safety measures.
Addressed to: Norfolk County Council
AI-generated concerns summaryThe coroner identified falsification of observation records for Mr Ali and in 11 other fatal incidents within the Trust. Concerns were raised that the Trust's actions to improve observation practice have not been sufficient to prevent continued falsification, indicating a risk of future deaths.
Addressed to: East London NHS Foundation Trust
AI-generated concerns summaryThe coroner noted significant backlogs for cardiology appointments, leading to patients waiting in excess of 40 weeks for specialist input, which increases the risk of complications and death for those needing timely care.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified gaps in the clarity of processes for NHS mental health referrals and crisis support involving private practitioners, noting insufficient information sharing and difficulties for private clinicians to refer patients to NHS crisis teams or access GP details.
Addressed to: Department of Health and Social Care; NHS England; South West London and St George’s Mental Health Trust
AI-generated concerns summaryThe coroner noted the railway station is perceived as a location for suicides, and recent incidents meet the British Transport Police's 'hot spot' definition, contrary to prior classifications.
Addressed to: Northern Rail
AI-generated concerns summaryThe coroner noted concerns about the lack of a rapid and secure handover process for urgent requests from GP surgeries to out-of-hours services, leading to delays and an inefficient patient journey. Concerns were also raised that referrals to 111 continue to cause delays and place undue pressure on the service.
Addressed to: Carlisle Healthcare; Cumbria Health
AI-generated concerns summaryThe coroner noted that individuals with cognitive deficits may miss important appointments if their next of kin are not consistently informed of short-notice changes, as there is no system to facilitate this communication.
Addressed to: Norfolk and Suffolk Foundation Trust
AI-generated concerns summaryConcerns focused on the lack of a national integrated healthcare system, diagnosis, and treatment pathways for Type 1 Diabetes with Eating Disorder, notably a mental health protocol for DKA. Shared clinical records also lack integration with private providers for NHS patients.
Addressed to: Department of Health and Social Care; Hertfordshire and West Essex Integrated Care Board
AI-generated concerns summaryThe coroner raises concerns about the recognition of suspected sepsis and the timely provision of treatment for it, noting a risk that sepsis will continue to go unrecognized and treatment delayed at Blackpool Victoria Hospital.
Addressed to: Blackpool Teaching Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of awareness of rhabdomyolysis among general paediatricians and limited available guidance, which could lead to future cases going unrecognized with fatal consequences.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the absence of a legal requirement for smoke alarms on privately owned boats, noting that this gap may increase the risk of fatalities from fire.
Addressed to: Boat Safety Scheme
AI-generated concerns summaryThe coroner noted that risk assessment and management were not fully integrated into care plans, and staff did not follow the emergency choking protocol. Additionally, the care home's internal investigation was deemed insufficiently thorough.
Addressed to: Serencroft
AI-generated concerns summaryA lack of evidence that an elderly patient living alone received clear instructions to resume anti-coagulation medication post-discharge raises questions about ensuring vulnerable patients are aware of critical advice.
Addressed to: The Trust
AI-generated concerns summaryThe coroner identified no protocol to warn patients of respiratory depression risks from medication with alcohol or drugs. There was also a lack of joined-up processes among clinical teams for safe discharge, information sharing, and family contact.
Addressed to: County Durham and Darlington NHS Foundation Trust; Tees, Esk and Wear Valleys NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of learning or teaching by the hospital following similar deaths from the same cause, specifically aortic dissection, after patients were discharged from the emergency department.
Addressed to: University Hospitals Morecambe Bay Trust
AI-generated concerns summaryThe University of Reading lacks named pastoral tutors for taught research students, making early identification of difficulties challenging, and has no clear process or individual responsibility for supporting students through academic suspension when experiencing severe mental health issues.
Addressed to: Reading University; Universities UK
AI-generated concerns summaryThe report highlights a lack of formal written communication and documentation between police officers and with the Liaison Diversion Service regarding individuals' mental health in custody. This includes insufficient documented mental health plans and a need for guidelines on assessing intoxicated individuals.
Addressed to: Midlands Partnership University NHS Foundation Trust; Mitie; National Police Chiefs’ Council; NHS England; Sussex Police
AI-generated concerns summaryConcerns were raised regarding the robustness of anti-thrombotic guidelines for dermatological surgery in frail patients, a lack of preoperative assessment and advanced consent, and the appropriateness of surgical technique for wound closure in fragile skin.
Addressed to: British Society for Dermatological Surgery; Sussex Community Dermatology Service