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 ambulance crew did not consider Co-codamol toxicity, and the Ambulance Service's lack of access to GP records meant a missed opportunity to administer Naloxone, which could have improved the outcome.
Addressed to: NHS Sussex Integrated Care Board
AI-generated concerns summaryThe coroner raised concerns regarding the absence of continued care for hydrocephalus patients in adulthood and the lack of a clear transfer protocol or pathway for their transition from childhood to adulthood. There was also no effective review process for adult patients with shunts.
Addressed to: Sheffield Children’s NHS Foundation Trust; Sheffield Teaching Hospital Trust NHS Foundation Trust
AI-generated concerns summaryThe coroner identified a national shortage of Consultant Histopathologists, which contributed to an incorrect cancer diagnosis and poses a widespread risk to patients due to insufficient national action to address the vacancies.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryPoor record keeping on the ward, including inconsistent charting and inadequate documentation of professional assessments, hindered the management of challenging behaviour and resulted in poor communication with the family. Additionally, no system was in place for agency staff to access communications or new policies.
Addressed to: Doncaster Royal Infirmary
AI-generated concerns summaryThe report identifies a lack of a Trust procedure for automatic cardiology referrals for inpatients with cardiac failure, resulting in delayed and sub-optimal management. Poor communication between services also caused a delayed approach to wound care.
Addressed to: Rotherham NHS Foundation Trust
AI-generated concerns summaryThe coroner identified inadequate knowledge among health board staff, including clinicians and site managers, regarding the correct procedure for booking urgent patient transfers via the Adult Critical Care Service Cymru (ACCTS).
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner raises concerns about insufficient training for police officers in recognising signs of drug intoxication and mental health conditions in detainees, including when hospital treatment is needed. There is also a lack of training regarding the heightened risk of positional asphyxia in intoxicated persons and no mandatory refresher training …
Addressed to: South Yorkshire Police Headquarters
AI-generated concerns summaryConcerns were raised about the lack of mandatory annual GP reviews for epilepsy patients and insufficient national guidance for their long-term monitoring and safe discharge. There was also an absence of clear pathways for urgent neurology reviews and essential information provision to patients upon discharge from secondary care.
Addressed to: NHS England; Royal College of General Practitioners; Royal College of Physicians
AI-generated concerns summaryThe coroner noted the chaotic response of ward staff to an emergency was due to a lack of adequate training in real or simulated emergency situations. Concerns were raised that staff still lack this essential simulation exercise training.
Addressed to: Central and North West London NHS Foundation Trust
AI-generated concerns summarySheffield City Council has not risk assessed high-rise windows after two fatalities, and the Building Safety Regulator was not consulted. There is a general lack of formal procedures for investigating and assessing risks following serious incidents in social housing.
Addressed to: Sheffield City Council
AI-generated concerns summaryThe coroner identified that an ambulance delay was caused by broader issues within healthcare services, specifically relating to delayed hospital discharges. This was due to insufficient social care provision, which led to hospital capacity issues, prolonged ambulance handover times, and increased ambulance response times.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted improper implementation and supervision of the ACCT procedure, with missed observations and false entries. Concerns were also raised regarding the adequacy of observation levels and the lack of transfer for psychiatric treatment.
Addressed to: HM Prison and Probation Service; Midlands Partnership NHS Foundation Trust; North Staffordshire Combined Healthcare NHS Trust
AI-generated concerns summaryClinicians and practitioners involved in discharging patients from in-patient mental health admissions lack training in the discharge process, particularly for out-of-area admissions.
Addressed to: Berkshire Healthcare NHS Foundation Trust; Cygnet Hospital; Reading Borough Council Adult Social Care
AI-generated concerns summaryProbation officers need to better understand the suicide/self-harm risk specific to IPP offenders and be fully versed in the processes for parole licence cancellation, as observed in Mr Williams' case where cancellation referral was missed.
Addressed to: Probation Service
AI-generated concerns summaryConcerns included the appropriateness of Mr Kinzley's care location and the absence of a formal capacity assessment. Furthermore, no mental health assessment was initiated despite his history of mental illness, self-harm, and deteriorating condition.
Addressed to: London Borough of Redbridge; Cambridge Nursing Home Ltd; Evergreen Surgery; Integrated Care Board (ICB) for North-East London
AI-generated concerns summaryConcerns focused on the Crisis Resolution Home Treatment Team's assessment practices, understanding of mental capacity, and knowledge of other services. Issues also involved uncirculated emails, inconsistent assessment response times, and the sufficiency of telephone support.
Addressed to: Department of Health and Social Care; Norfolk and Suffolk NHS Foundation Trust
AI-generated concerns summaryAn ambulance delay contributing to Robert's death was linked to a systemic failure where insufficient social care provision led to delayed hospital discharges. This caused patient backlogs in hospitals, impacting ambulance availability and response times.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted that buses designed for urban use and therefore exempt from seatbelt requirements are still used on long-distance, high-speed rural routes, raising concerns about passenger safety in collisions.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified a lack of a system or protocol to alert clinicians to review concerning responses to an automated questionnaire when a patient has cancelled their appointment or the assessment appointment is not for several days/weeks.
Addressed to: South London and Maudsley NHS Foundation Trust
AI-generated concerns summaryThe coroner identified issues with the efficiency of information transfer, noting that improvements were needed to streamline this process.
Addressed to: EMIS Health; Phoenix Partnership