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 individuals can be removed from a GP surgery without scrutiny of their need for vital medication, and there is no process to ensure continued medication access after deregistration, particularly when a new GP is not known.
Addressed to: Chelsfield Surgery
AI-generated concerns summaryThe coroner identified that patient smoking status was not routinely recorded in an easily accessible format in GP records, hindering relevant clinical decisions. Additionally, the process for applying NICE guidelines for chest x-ray referrals was informal, risking inconsistent application by staff.
Addressed to: Ringmead Medical Group
AI-generated concerns summaryDelays in cancer diagnosis and treatment, alongside a failure to promptly manage a gastrostomy leak and sepsis, resulted in delayed emergency care. The report also notes poor clinical record standards and insufficient controlled drug management systems.
Addressed to: Barking, Havering and Redbridge University Trust; Department of Health and Social Care; Medicine and Healthcare products Regulatory Agency
AI-generated concerns summaryThe unavailability of the surgeon's preferred cannula due to supply issues led to a shorter-tipped alternative being used. This cannula contributed to its dislodgement and Mr Walton's death, highlighting risks when equipment choice is restricted.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryA section of Butsfield Lane in Consett, featuring a steep gradient and a bend, poses a hazard and risk of death to road users in slippery conditions due due to the absence of effective mitigation.
Addressed to: Durham County Council
AI-generated concerns summaryThe coroner noted the absence of lifeguards after August 31st during tourist season at Rethymno, Crete. This, combined with rough sea conditions and a lack of warning markers, made swimming unsafe.
Addressed to: Foreign, Commonwealth and Development Office; Greek authorities
AI-generated concerns summaryThe coroner noted financial pressures on Mr McHale due to housing benefit rules, which led to rent arrears and fear of eviction. This situation was exacerbated by his concern for an adult foster child becoming homeless if he moved.
Addressed to: Ministry of Housing, Communities & Local Government
AI-generated concerns summaryThe coroner noted concerns about a lengthy, defective, and subsided section of road on Station Road, where accumulated standing water could freeze and cause vehicles to lose grip, especially on a bend.
Addressed to: Highways Authority of Derbyshire County Council
AI-generated concerns summaryThe coroner notes a lack of evidence-based protocol for managing DOAC medication, which has resulted in inconsistent clinical practice among healthcare professionals.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryThe coroner noted that district nurses encounter difficulties obtaining correct authorisations for medicines, and there is no specific guidance for 'Time Critical Medicine' in community settings.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified significant delays in patients accessing cardiologist appointments and essential diagnostic tests due to high demand and a shortage of qualified professionals. Communication delays between two different trusts, caused by incompatible IT systems, also impacted the timely update of patient records.
Addressed to: Greater Manchester Integrated Care; NHS England
AI-generated concerns summaryThe Trust's Antepartum Haemorrhage guideline did not convey urgency regarding potential sinister causes of bleeding, and there was no clear system to capture early reflective accounts from staff following significant events.
Addressed to: Sherwood Forest Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that a recommended staggered prescription cycle to limit medication access was not implemented due to concerns about potential confusion and incorrect prescribing. No further investigation was made into how other practices manage such prescribing or available safety measures to prevent errors.
Addressed to: Park Surgery
AI-generated concerns summaryThe coroner noted a lack of joined-up care between treatment for menopausal symptoms and mental health issues, alongside insufficient understanding among professionals about the link between menopause and mental health decline. There is also an absence of national or local guidance on this topic.
Addressed to: National Institute for Healthcare and Clinical Excellence; NHS England; Somerset Foundation Trust
AI-generated concerns summaryThe coroner noted the absence of residential substance misuse treatment facilities for children under 18 in England, creating a disparity with adult services and increasing the risk of relapse and overdose for young persons.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner raised concerns regarding the safe prescribing of warfarin, noting that doctors rely on nurses for information without reviewing medical records, which carries a risk if critical patient information is not fully communicated.
Addressed to: University Hospitals of Leicester NHS Trust
AI-generated concerns summaryThe coroner noted that Evolve Services' medication administration records and care plans were insufficient for the safe administration of thickened fluids, and a recommended audit to address this was not completed after four months.
Addressed to: Evolve Services
AI-generated concerns summaryPolice officers, including those with enhanced first aid training, lacked understanding of agonal breathing and early signs of cardiac arrest. The coroner noted that current police first aid curricula do not adequately cover these recognition skills, suggesting improved training methods using video footage.
Addressed to: College of Policing
AI-generated concerns summaryThe coroner noted a lack of clear and detailed handover between doctors during a patient's transfer, an unagreed treatment plan, and insufficient documentation. A prescription error also delayed the administration of hydrating fluids.
Addressed to: Cornwall Partnership NHS Foundation Trust; Royal Cornwall Hospitals NHS Trust
AI-generated concerns summaryThe coroner notes a lack of public understanding regarding the dangers of lithium-ion batteries in e-bikes and e-scooters. There are also no British or European standards to control the sale of these batteries and chargers in the UK.
Addressed to: Department for Transport; Office for Product Safety and Standards; West of England Combined Authority