Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner identified a lack of clear systems for following up missed urology appointments and for inter-team communication between departments involved in patient care. Concerns were also raised regarding an inappropriate telephone appointment offered to a patient with documented hearing difficulties.
Addressed to: Worcestershire Acute Hospitals NHS Trust
AI-generated concerns summaryConcerns included insufficient dietetic staffing, inadequate staff training for pressure sore care, and insufficient IT training for agency staff. Additionally, issues were noted with dietary supplement orders not being processed by the hospital's computer system.
Addressed to: Frimley Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns regarding the overall sufficiency of staffing arrangements for the Emergency and Paediatrics departments, as only 60% of doctors were available for these services.
Addressed to: South Essex NHS Partnership
AI-generated concerns summaryThe coroner identified concerns regarding Quora's hosting of sensitive content accessible to children without age verification. The platform also has features that encourage consumption of such material and insufficient content monitoring against its own policies.
Addressed to: Department for Culture, Media and Sport; OFCOM; Quora
AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about future deaths of at-risk prisoners.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner identified significant gaps in multi-agency coordination and policy application for missing high-risk mental health patients. Concerns include inadequate risk rating handover, insufficient procedural monitoring, and communication breakdowns between mental health services and police on searches and risk challenges.
Addressed to: Association of Police and Crime Commissioners; Birmingham and Solihull Mental Health Foundation Trust; College of Policing; Department of Health and Social Care; Home Office; National Police Chiefs’ Council; NHS England; West Midlands Police
AI-generated concerns summaryThe coroner noted a lack of formal systems to assess the mental health impact on vulnerable parents during child services interventions or to provide independent support. Concerns were also raised about the difficulty in securing funding for specialist therapy.
Addressed to: Department of Health and Social Care; Home Office; Norfolk and Suffolk NHS Foundation Trust; Norfolk and Waveney Integrated Care Board; Suffolk Constabulary Police Headquarters; Suffolk County Council; House of Commons
AI-generated concerns summaryConcerns included the inappropriate transfer of a prisoner with complex mental health needs to a facility with limited healthcare. This was due to insufficient handover between healthcare teams and no national directory detailing prison healthcare provisions.
Addressed to: Department of Health and Social Care; HMP Guys Marsh; HM Prisons and Probation Service; NHS England; Unilink Software Ltd
AI-generated concerns summaryDifferent electronic patient record systems between two hospitals within the same trust resulted in medical entries and allergy information not being automatically visible or cross-populated between sites.
Addressed to: Department of Health and Social Care; University Hospitals of Derby and Burton NHS Foundation Trust
AI-generated concerns summaryThe coroner noted delays in X-ray reporting due to a national radiologist shortage, leading to ED doctors interpreting films under pressure and diverting consultant resources. Training gaps exist in primary care for recognising critical pain from healing fractures.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted that guidance within the College of Policing APP could be clearer. This clarity may help officers achieve greater consistency in decision-making when assessing the risk level for missing persons reports.
Addressed to: College of Policing
AI-generated concerns summarySub-optimal delays in accessing IAPT counselling were noted. Concerns were also raised about the clarity and accessibility of electronic patient records, particularly regarding the updating and function of risk assessments and progress notes.
Addressed to: Midlands Partnership NHS Foundation Trust
AI-generated concerns summaryThe coroner raises concerns about the lack of consistent and clear guidance for Mental Health trusts regarding the definition and conduct of Section 17 leave, particularly concerning patient supervision definitions and practical instructions for staff.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe coroner noted that the Early Years Foundation Stage framework only requires one paediatric first aid certified staff member, which may be insufficient during an emergency. Concerns were also raised that the three-year validity period for PFA training may lead to skill degradation without refresher courses.
Addressed to: Department for Education
AI-generated concerns summaryThe coroner noted that significant learning identified by the Health Board, regarding timely escalation and fluid balance charting for surgical nurses, has not been fully rolled out due to resourcing issues and its non-compulsory nature.
Addressed to: Cwm Taf Morgannwg University Health Board
AI-generated concerns summaryConcerns included insufficient staffing and supervision for probation officers and police Sexual Offender Management Units. The coroner also identified limited information sharing protocols with external services and poor quality internal investigations by Greater Manchester Police.
Addressed to: Department of Health and Social Care; Greater Manchester Police; Home Office; Ministry of Justice; Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that a national shortage of District Nurses caused a delay in Mr. Hartey's urgent referral being actioned, leading to him not being seen in a timely manner.
Addressed to: Department Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding staff non-compliance with eating and drinking guidelines, inadequate recording of mealtime strategies, and insufficient monitoring by management. Additionally, there was an apparent failure to provide the full level of funded support for Peter.
Addressed to: Cygnet Health Care
AI-generated concerns summaryThe coroner noted the absence of out-of-hours interventional radiology at Dorset County Hospital, requiring patients needing urgent treatment to be transferred to the Royal Bournemouth Hospital.
Addressed to: Dorset County Hospital NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns that vascular calcification on an x-ray, which could indicate Peripheral Vascular Disease, was not recorded in the report. This non-reporting appeared to be standard practice at Warrington Hospital, deviating from expected standards.
Addressed to: Warrington Hospital