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 heard evidence regarding the appropriate level of observation by Emergency Department staff for mental health patients waiting in the Emergency Department.
Addressed to: West Hertfordshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inadequate risk assessment for a patient with a self-harm history regarding room suitability with a faulty anti-ligature mechanism. Risks of medication and alcohol interaction were not communicated, and family concerns about the patient leaving with medication received no action.
Addressed to: Essex Partnership NHS Trust
AI-generated concerns summaryThe coroner raised concerns that a Critical Care Team was not immediately dispatched and a rapid response vehicle was not deployed due to the application of an End Of Shift Policy, despite clear evidence of patient deterioration during the 999 call.
Addressed to: East of England Ambulance Service
AI-generated concerns summaryThe coroner noted the lack of advance warning signs for a layby situated at the bottom of a dip, which was unforeseen by the driver due to a hill brow. Better placement or early signposting of the layby might have prevented the collision.
Addressed to: Ilkley Town Council
AI-generated concerns summaryPrison healthcare was unaware of the deceased's recent severe anxiety treatment and medication because the NHS Spine does not transmit records from temporary GP practices. This lack of access to information was a contributing factor in his death.
Addressed to: NHS England
AI-generated concerns summaryIt is not mandatory for prison officers to maintain in-date basic first aid training, including CPR. This results in a significant proportion of staff having expired certifications.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted the absence of a regulatory authority to control the quality or airworthiness of the specific class of paraglider, including a lack of mandatory inspection and certification. This absence provides an opportunity for future deaths to occur.
Addressed to: RPAS
AI-generated concerns summaryThe coroner noted that paramedics attending Peter had no training in identifying a herald bleed, nor any protocol to follow for such a condition.
Addressed to: Yorkshire Ambulance Service
AI-generated concerns summaryThe coroner raised concerns about insufficient information sharing and a lack of joint working between District Nurses, the care home, and the GP regarding pressure ulcer management. These issues led to incomplete care plans, limited family involvement, and ineffective remote expert reviews.
Addressed to: Care Quality Commission
AI-generated concerns summaryThe coroner identified significant gaps in information sharing and joint planning between the Health Board and an out-of-area private psychiatric unit, leading to delays in receiving critical discharge information. There was no formal written agreement or standard operating procedure for communication standards between the organisations.
Addressed to: Betsi Cadwaladr University Health Board; Elysium Healthcare
AI-generated concerns summaryClinical notation by advanced nurse practitioners was inadequate as it did not sufficiently explain patient presentation to enable appropriate escalation of care.
Addressed to: Clatterbridge Cancer Centre
AI-generated concerns summaryThe coroner raised concerns that seasonal lifeguards were ineligible for furlough, leading to staff shortages, and that the RNLI received no advance notice of lockdown relaxation, making it impossible to provide lifeguards when beaches reopened. Difficulties in sourcing PPE were also noted.
Addressed to: Cabinet Office
AI-generated concerns summaryPeabody support workers, providing 24-hour solo support in supported living accommodation, are not required to have certificated First Aid and Basic Life Support training. This absence of formal training for solo providers for vulnerable residents presents a risk of future deaths.
Addressed to: Care Quality Commission; Peabody; Skills for Care
AI-generated concerns summaryThe coroner noted an active website providing downloadable step-by-step instructions and a direct link to a company supplying materials for ending one's life, accessible to anyone online.
Addressed to: Department for Science, Innovation & Technology; National Crime Agency
AI-generated concerns summaryThe coroner identified concerns regarding out-of-area mental health placements resulting from bed shortages, which impeded family contact and information sharing. Issues also included coordinating teams' insufficient understanding of local care pathways and effective discharge planning.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns regarding persistent staff recruitment issues and bed unavailability, which impacted patient access to community mental health services and led to long therapy waiting lists. Additionally, the family received incorrect advice about treatment commissioning and their rights.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryHospital discharge summaries often contain inadequate information regarding patients' frailty and mobility, hindering care homes' ability to conduct appropriate ongoing risk assessments. Concerns were also raised that social workers frequently do not complete pre-discharge risk assessments.
Addressed to: Hull University Teaching Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of regular review for individuals with allergies and anaphylaxis risk, highlighting the need for a systematic approach to education, review, and management to prevent future deaths.
Addressed to: Department of Health and Social Care; Newcastle City Council; NHS England
AI-generated concerns summaryThe coroner raised concerns that clinicians attributed patient deterioration to old age, potentially leading to missed treatable conditions instead of considering the whole clinical picture.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner expressed concern that the junction design is confusing for pedestrians, as the green light for some lanes is not visible and there are no pedestrian light indications on the opposite side, potentially leading to misjudgement of traffic flow.
Addressed to: Sandwell Highways