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 summaryConcerns were raised regarding pre-populated, non-event-specific risk assessments and the absence of a mandatory recorded safety plan for Club/National ACU track race events. This lack of methodical safety planning risks future deaths.
Addressed to: Auto Cycle Union
AI-generated concerns summaryThe coroner raised concerns about the inability to access inpatient mental health beds at the time of clinical need, noting a national increase in people waiting for beds and the risk of future deaths as a result.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted the absence of specific guidance for managing and expediting discharge of high-risk immunosuppressed patients in acute hospital settings. Concerns were also raised about insufficient monitoring of kidney function, which contributed to opiate toxicity and delayed discharge.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted Amitriptyline was prescribed above recommended doses and for an unadvised condition, contrary to BNF guidelines. An overdose risk was not flagged, and a change to monthly prescriptions by a less familiar GP provided increased access.
Addressed to: Tredegar Practice
AI-generated concerns summaryThe coroner highlighted a risk of future deaths on a specific stretch of the A1307 road unless the risk of flooding and standing water is reassessed and managed. This follows multiple incidents of vehicles hitting water patches, leading to injury or death.
Addressed to: Cambridgeshire County Council
AI-generated concerns summaryThe report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for unexpected emergencies and the potential for improved control room measures.
Addressed to: HMP Styal; Ministry of Justice
AI-generated concerns summaryThe coroner noted risks associated with mental health unit admissions occurring during staff handover, specifically confusion over responsibility for admission tasks and the lack of a formal policy to manage admissions during these times.
Addressed to: Derbyshire Healthcare NHS Trust
AI-generated concerns summaryThe specific concerns to prevent future deaths could not be identified as they were not included in the provided document.
Addressed to: Berkshire Healthcare NHS Foundation Trust; Home Office; Midlands Partnership University NHS Foundation Trust; Ministry for Justice; NHS England; Oxford Health NHS Foundation Trust; Thames Valley Police
AI-generated concerns summaryThe coroner noted a significant delay of nearly nine hours in ambulance response for an Amber 1 patient, who died before arrival, with hospital handover delays identified as a contributing factor.
Addressed to: Aneurin Bevan University Health Board
AI-generated concerns summaryThe coroner noted concerns that prison officers in facilities without 24-hour healthcare are not trained to assess rigor mortis, a condition included in CPR guidance, which risks missed opportunities for resuscitation.
Addressed to: Ministry of Justice
AI-generated concerns summaryConcerns were raised about the lack of mandatory first aid training for student accommodation staff, and the Crisis Team's Standard Operating Procedure regarding proactive information gathering from other agencies for patients not yet under their direct care.
Addressed to: Leicestershire Partnership Trust; Student Roost
AI-generated concerns summaryThe coroner noted a lack of clarity regarding who should make the decision to abort an open-water swim and when, along with insufficient communication of this to family. This situation can result in unnecessary delay and increased risk.
Addressed to: Anastasia Boat; Channel Swimming Pilot Federation; Pilot of the "Anastasia"
AI-generated concerns summaryThe coroner noted a lack of local guidance for implementing NICE NSAIDs prescribing and that prescribing software did not automatically warn about NSAID risks. Discharge documentation also lacked warnings for community primary care prescribers regarding NSAID considerations.
Addressed to: Lincolnshire Integrated Care Board
AI-generated concerns summaryStaff did not receive timely training and guidance on how and when to enter a cell during a medical emergency, nor on the appropriate use of Code Blue and Code Red communications.
Addressed to: HM Prison and Probation Service; Ministry of Justice; Swinfen Hall
AI-generated concerns summaryThe coroner identified that the online Risk Assessment Tool (EPJS) is not used in line with policy, with detailed indicators not being systematically reviewed. This can lead to risk assessments based on incomplete or misleading information.
Addressed to: Department of Health and Social Care; NHS England; South London and Maudsley NHS
AI-generated concerns summaryThe coroner identified an inaccurate discharge summary and an absence of a plan for reassessment if the patient's condition worsened. Inadequate communication with the nearest relative and perceived patient capacity as a barrier to further care were also noted.
Addressed to: CIOS ICB; Cornwall Council; Cornwall & Isles of Scilly Integrated Care Board; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding the lack of proper documented patient observations, which hindered the ability to track a patient's decline. There were also insufficient doctors on duty to manage more than one critically unwell patient, and potential delays in obtaining blood products stored outside the ED.
Addressed to: University Hospitals Birmingham NHS Foundation
AI-generated concerns summaryThe electronic prescription system at Royal Surrey Hospitals NHS Foundation Trust risks medications ceasing inadvertently because alerts for prescription reviews are only shown to prescribers when they access a patient's record. This could lead to a delay in renewing essential medication.
Addressed to: NHS England; NHS Improvement; Oracle UK Limited
AI-generated concerns summaryThe coroner identified a lack of formal policies and guidance defining responsibilities between CCTV operators and West Mercia Police, leading to delays in calling emergency services. A relevant agreement remained uncompleted over a year later.
Addressed to: West Mercia Police; Wychavon District Council
AI-generated concerns summaryInadequate oral care led to untreated oral thrush and malnutrition, while insufficient mobilisation contributed to a severe pressure sore. The discharge summary was misleading, failing to detail the sore's severity or Mrs Divall's end-of-life care status.
Addressed to: East Sussex Healthcare NHS Trust