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 summaryThere is no formal requirement to risk assess patients for communication difficulties or their ability to use a call bell when placed in a side room, making it difficult for them to attract staff attention in an emergency.
Addressed to: Norfolk and Norwich University Hospitals
AI-generated concerns summaryThe Coal Authority lacked a specific water safety policy and guidance for inspectors regarding risks to the public. Remedial works identified for unsafe site aspects were not carried out, and documentation was not easily accessible.
Addressed to: Coal Authority
AI-generated concerns summaryPoor surgical planning led to a colorectal surgeon's absence and incorrect antibiotic prescribing due to insufficient knowledge of guidelines. The report also highlights insufficient post-operative vigilance, inadequate nursing documentation, and a lack of physical assessment prior to discharge.
Addressed to: James Cook University Hospital
AI-generated concerns summaryThe coroner identified that the call handler did not detect a worsening condition and failed to escalate the call. Methods for detecting worsening conditions in existing Category 2 calls were not sufficiently robust, and the ambulance response time target was breached.
Addressed to: Department of Health & Social Care; North East Ambulance Service Foundation Trust
AI-generated concerns summaryFamily received no advice on options or services when they raised concerns for their family member's safety. No alternative service was considered to mitigate the risk of emotional dysregulation when the initially identified service was unavailable.
Addressed to: South West Yorkshire Partnership Trust
AI-generated concerns summaryThe coroner noted a lack of Datix reporting and investigation into how a patient was lost to follow-up. Concerns were raised regarding staff time restraints and the Datix system's usability hindering internal governance processes.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified a practice of staff deliberately ignoring cell bells and a lack of policy regarding isolating power to cells. There was also a failure to follow the 'Under the Influence Policy' and insufficient staff understanding of Prison Service Instruction 64/2011 concerning trigger dates.
Addressed to: HM Prison and Probation Service; Sodexo
AI-generated concerns summaryThe coroner raised concerns about academic staff awareness and understanding of student mental health, noting non-compulsory training and insufficient guidance on identifying struggles, especially for neurodiverse students. A gap between academic assessment and pastoral support was also identified.
Addressed to: University of Southampton
AI-generated concerns summaryThe coroner noted concerns that clinical guidelines do not identify healthcare professionals as a heightened risk group for TB exposure, and the definition of 'close contact' for staff notification is too narrow. There is also insufficient education for NHS staff on TB symptoms, and the 'warn and inform' process needs …
Addressed to: National Institute for Clinical Excellence; NHS England; UKHSA
AI-generated concerns summaryThe coroner noted delays in the London Fire Brigade's attendance and concerns that an extended height ladder appliance was not requested from the outset for a person on a block of flats roof.
Addressed to: London Fire Brigade
AI-generated concerns summaryThe initial police investigation did not adequately consider information about the deceased's drug sourcing via the "Dark Web" and Royal Mail, resulting in a delayed investigation and the loss of critical time-sensitive evidence.
Addressed to: Humberside Police
AI-generated concerns summaryThe coroner noted that the hotel lacked a fully trained first aid employee for 24 hours, with cover only from 7am to 7pm. Additionally, not all staff had basic first aid training, including practical components, which could hinder responses to medical emergencies.
Addressed to: Travel Lodge
AI-generated concerns summaryThe coroner raises concerns about the absence of effective barriers or warnings on the promenade for individuals on mobility scooters, especially as current signage does not address the risk of users falling asleep and falling from variable-height drops.
Addressed to: East Suffolk Council
AI-generated concerns summaryClinicians at Sandwell and West Birmingham Hospital were unaware of guidelines for referring patients with strong clinical signs of a brain bleed to specialist neurosurgical advice when a lumbar puncture was refused. Clearer guidance is needed for acute trusts on this referral process.
Addressed to: Sandwell and West Birmingham Hospitals NHS Trust; University Hospitals Birmingham NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a severe lack of suitable specialist placements and beds for young adults with autism who are at risk of self-harm or harm to others, leading to an unsuitable hospital stay and limited options for urgent care.
Addressed to: NHS England; NHS Kent and Medway Clinical Commissioning Group
AI-generated concerns summaryInsufficient monitoring and management of a prisoner's epilepsy, including no seizure care plan or diary, was identified. There were also inadequate communication between staff and family, and a lack of specific training for prison officers on long-term health conditions.
Addressed to: HM Prison and Probation Service; Practice Plus Group
AI-generated concerns summaryThe coroner noted deficiencies in record keeping regarding referral outcomes, readmission considerations, and comprehensive risk assessments. Concerns were also raised about care plans lacking individual tailoring and omitting risk management and contingency planning.
Addressed to: Essex Partnership NHS Trust
AI-generated concerns summaryNorthampton General Hospital cannot consistently provide immediate chest ultrasounds for children with pneumonia due to limited access to paediatric radiologists outside of specific weekday hours. This unavailability could result in delays of up to 48 hours for urgent diagnostic scans.
Addressed to: NHS England; NHS Northamptonshire Integrated Care Board; Northampton General Hospitals NHS Trust
AI-generated concerns summaryNo specific concerns were detailed in the provided text fragment from the coroner's report.
Addressed to: British Drilling Association; Pipeline Industries Guild
AI-generated concerns summaryIneffective communication and incomplete documentation between clinical and nursing teams were identified. The report also notes a lack of clear policies for escalating missed critical medications, reconciling drugs, and determining safe discharge, alongside insufficient understanding of the VTE policy.
Addressed to: Lancashire Teaching Hospitals; NHS England