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 underfunding for local mental health beds and a national scarcity of specialist Personality Disorder rehabilitation units, which contributed to delayed patient transfers and prolonged stays in unsuitable out-of-area placements.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted the lack of flumazenil, an antagonist, carried by paramedics and ambulance crews, which could be critical in acute community circumstances. No explanation was provided for its absence compared to other carried antagonists.
Addressed to: Welsh Ambulance Service NHS Trust
AI-generated concerns summaryDue to agitation, Harry's physical health observations were insufficient in the emergency department and on the Mason Unit. Additionally, mental health nursing staff were unaware that Acute Behavioural Disturbance is a medical emergency.
Addressed to: Royal College of Nursing
AI-generated concerns summaryThe coroner noted concerns regarding the functionality and documentation of Multi-Disciplinary Team meetings, including unexplained risk downgrades and insufficient record-keeping of decision processes. Issues were also identified with incomplete risk assessments and staff conducting 'Safe and Well' calls without reviewing patient medical records.
Addressed to: Leicestershire Partnership NHS Trust
AI-generated concerns summaryThe coroner noted that the Health and Safety Executive's (HSE) investigation selection criteria did not cover serious injuries like paraplegia or incidents under RIDDOR 4(2), and lacked a discretionary option for investigation. This absence of a prompt investigation resulted in lost evidence and made it difficult to establish facts to …
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner noted a lack of awareness among medical professionals regarding a rare drug complication, potentially delaying diagnosis. The consenting process also typically omits rare complications, hindering informed patient decisions.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted inadequate mental health bed capacity in London, leading to significant delays for patients needing mental health placements, with one patient waiting six days for a bed.
Addressed to: Department of Health and Social Care; NHS South West London Integrated Care Board; South West London and St George’s Mental Health NHS Trust
AI-generated concerns summaryThe Trust discharged a patient without treating a fractured clavicle or providing pain relief and a care package. The discharge summary also omitted details of the fracture, leading to a delay in appropriate care until the patient's GP intervened.
Addressed to: Princess Alexandra NHS Trust
AI-generated concerns summaryConcerns are raised that important medical information recorded in patient notes was not visible or immediately accessible to treating clinicians due to how entries are displayed and reliance on verbal handovers.
Addressed to: County Durham and Darlington NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the online sale of prescription drugs, specifically Zopiclone, in quantities and doses exceeding medical prescriptions, which increases the risk of overdose and complicates safe prescribing.
Addressed to: Department for Digital Culture, Media and Sport; Department of Health and Social Care
AI-generated concerns summaryThe ambulance triage process for suspected ingestion incidents does not allow sufficient time for critical interventions. Additionally, there is no regional or national protocol for ambulance services to carry and administer specific antidote medication on-scene.
Addressed to: Association of Ambulance Chief Executives; National Ambulance Resilience Unit; NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS; NHS England
AI-generated concerns summaryThe coroner identified delays in repairing a broken wrist alarm, preventing a vulnerable person from summoning help. Concerns include carers not addressing the issue, lack of training on alarm testing, and unclear fault reporting procedures between care providers and the local authority.
Addressed to: London Borough Hackney; Supreme Care Services Limited
AI-generated concerns summaryThe coroner raised concerns about insufficient clarity and inconsistent application of weight difference criteria for matching boxers in charity events. Discrepancies were noted in training regimes, and planned new training standards, not yet implemented, risked inadequate instruction for participants.
Addressed to: Department for Digital Culture, Media and Sport; Ultra Events Ltd
AI-generated concerns summaryStaff attending Mr Lee after he used his alarm did not consider he might be choking, and therefore no life-saving techniques were attempted despite recent food consumption.
Addressed to: Abbotswood; Care Outlook Ltd
AI-generated concerns summaryNHS Pathways does not trigger a more urgent response based on repeated 999 calls over time, relying on the caller's assessment. The automated duplicate checker relies on location rather than patient name, potentially missing repeat calls and leading to incorrect ambulance dispatch locations.
Addressed to: NHS England; West Midlands Ambulance Service
AI-generated concerns summaryThe coroner identified insufficient clinician awareness and adherence to NICE guidelines for adrenal insufficiency treatment. Concerns were also raised that crowded hospital environments and high staff turnover contribute to difficulties in applying these guidelines.
Addressed to: NHS England; Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted inadequate assessment of Mr Akramuzzaman's wellbeing, with officers relying solely on non-verbal cues and not conducting follow-up checks despite cold weather. There was also insufficient evidence of specific learning or procedural changes by British Transport Police after the incident.
Addressed to: British Transport Police
AI-generated concerns summaryThe coroner identified a lack of oversight and systems within the Emergency Department for patient management, urgent test results, and ensuring repeat investigations. Concerns were also raised regarding the ambulance service's call algorithm and subsequent delays in responding to time-critical conditions.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a lack of a system at Worcestershire Royal Hospital to ensure instructions for mechanical thromboprophylaxis are carried out, noting an instruction was not entered on a patient's drug card and consequently not actioned for 18 days.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryIpswich Hospital had inadequate arrangements for highlighting uncompleted risk assessments and for handing over tasks like falls assessments between shifts, leading to a patient not being assessed after a ward transfer.
Addressed to: East Suffolk and North Essex NHS Foundation Trust