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 summaryIneffective communication within the nursing home meant staff on duty were unaware of family concerns regarding Mr Costello, who was nil-by-mouth but reported drinking tap water.
Addressed to: Stockton Care Limited
AI-generated concerns summaryThe coroner identified gaps in GP understanding of timely and detailed referrals to vascular services and prompt referrals to District Nurses. Concerns also raised about poor communication across Greater Manchester Trusts.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner noted that current guidance from NICE and the British Society of Gastroenterology regarding anticoagulation strategy for patients with coronary stents undergoing therapeutic endoscopy may not reflect best practice, which includes pre-operative cardiology consultation.
Addressed to: British Society of Gastroenterology; National Institute for Health and Care Excellence; NHS England
AI-generated concerns summaryThe coroner noted ongoing delays in North West Ambulance Service attending Category 2 calls due to staff and vehicle shortages. Additionally, ambulance resources could not be fully utilised because of delays in clearing A&E departments due to wider NHS pressures.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner highlighted that paramedics lack access to rapid-acting analgesics, such as mucosal fentanyl lozenges, due to controlled drug legislation, which delays immediate pain relief and can impact patient treatment and extrication.
Addressed to: Home Office
AI-generated concerns summaryThe coroner identified insufficient interagency communication and information sharing for high-risk prisoners with mental health needs upon release, highlighting fragmented IT systems and a lack of cross-agency guidance for community support.
Addressed to: Birmingham and Solihull NHS Foundation Trust; G4S; HMPPS; Swansea Bay University Health Board; West Midlands Police
AI-generated concerns summaryThe coroner noted significant delays in patients accessing specialist immunology services due to a national shortage of qualified staff and high vacancy levels, which recruitment efforts were not resolving.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raises concerns about prison staff at HMP Lewes failing to carry out required roll checks, noting confusion over requirements and a lack of understanding of their importance. There are also insufficient measures to monitor staff compliance with these checks.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner raises concerns that original pack dispensing guidance for medications like Zuclopenthixol dihydrochloride, due to its special container status, can endanger patients with a history of suicidal risk and previous overdose attempts. A review of this guidance is suggested.
Addressed to: General Pharmaceutical Council; Lundbeck Limited; Medicines and Healthcare Products Regulatory Agency; National Pharmacy Association
AI-generated concerns summaryThe coroner identifies a knowledge gap among the public and some practitioners regarding immune deficiency in Down Syndrome and sepsis. NHS111 health advisers' lack of access to GP electronic summaries meant crucial diagnoses were missed, impacting patient assessment.
Addressed to: NHS England
AI-generated concerns summaryThe GP surgery could not demonstrate improvements in procedures, staffing, or training for recording patient calls, escalating enquiries to GPs, and monitoring GP call-backs to patients.
Addressed to: Church Elm Lane Medical Practice
AI-generated concerns summaryThe coroner raised concerns regarding the inadequate availability of informal mental health inpatient beds, noting that this issue persists both locally and nationally and has not improved since 2020.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner identified issues with the quality and completion of residents' care documentation. Concerns were also raised regarding procedures for escalation or non-escalation following a fall and subsequent medical intervention.
Addressed to: Credenhill Court Rest Home
AI-generated concerns summaryThe report describes a lack of consultant assessment for a complex patient, no proactive care during a mental health crisis, and insufficient consideration of impulsive suicide risk. There was also no follow-up after an interrupted session and inadequate communication between treatment teams.
Addressed to: Central and North West London NHS Foundation Trust; NHS England
AI-generated concerns summaryNo medical professional discussed the patient's driving or DVLA notification after hospital discharge, despite opportunities to do so. Dorset Healthcare University NHS Foundation Trust also lacked a written policy for assessing patient fitness to drive and contacting the DVLA at the time.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe SystmOne electronic patient system in prisons lacks an automated warning flag to identify when prisoners do not collect or dispense prescribed medication, hindering early identification of non-compliance and requiring an inefficient manual cross-check.
Addressed to: NHS England
AI-generated concerns summaryThe coroner noted evidence of frequent public access to railway tracks in the Hackney Central/Dalston Kingsland area. This access was facilitated by a low wall and various items of street furniture, including an electrical box, which may undermine safety measures.
Addressed to: London Borough of Camden; London Borough of Hackney; Network Rail
AI-generated concerns summaryThe coroner noted that safety systems intended to prevent unauthorised access to Tavistock Chambers were ineffective. This included a key fob entry door being hooked open and a secondary access point not being properly secured, despite previous incidents.
Addressed to: Camden Council
AI-generated concerns summaryThe coroner noted insufficient information sharing with carers regarding the patient's self-harm risk and medication management, inadequate communication of discharge medication recommendations by the psychiatrist, and a lack of universal understanding of the "DSH" abbreviation among medical staff.
Addressed to: Dartford and Gravesham NHS Trust; Kent and Medway NHS and Social Care Partnership Trust
AI-generated concerns summaryUltrasound reports and images from a private provider were not shared with the patient's treating clinicians or fully with the GP, delaying urgent care. This identifies a gap where community private imaging is not uploaded to the central PACS system, unlike NHS trust imaging, posing a risk to patients.
Addressed to: Kent and Medway Integrated Care Board