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 report describes a lack of clear guidance regarding Acyclovir prescription, noting that intravenous Acyclovir might have prevented Nuel-Junior's death if clearer guidance had been available.
Addressed to: National Institute for Health and Care Excellence; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted that training provided to the manager and support worker regarding the movement of injured people was insufficient and unmemorable, leading to it being disregarded and risking worsened injuries.
Addressed to: Choice Support
AI-generated concerns summaryThe coroner notes a lack of documented discussions with patients regarding the risks of stopping medication, which contravenes NICE guidance. Concerns are also raised that significant event meetings following deaths are delayed, hindering timely learning.
Addressed to: Stretton Medical Centre
AI-generated concerns summaryThe coroner identified issues with flooding and the general condition of the A539 highway, particularly near the Sun Trevor Public House, which were reportedly known to the Local Authority. These conditions pose a risk of future deaths.
Addressed to: Denbigshire County Council
AI-generated concerns summaryThe coroner noted that pre-surgical communication between surgeons and patient's consultants was not a documented or approved part of the health board's protocols for "pooled lists", raising concerns about cohesive patient care.
Addressed to: Betsi Cadwaladr University Health Board; Welsh Government
AI-generated concerns summaryParamedics caused a 30-minute delay by not adequately checking an unlocked door. This failure was not investigated or considered in the Serious Incident review, and the option of a taxi for quicker hospital transport was not explored.
Addressed to: North East Ambulance Service NHS Foundation Trust
AI-generated concerns summaryThe coroner raised concerns about the impact of the Ofsted inspection system on school leader welfare, identifying a lack of Ofsted training and clear policies for addressing distress during inspections. The report also noted the absence of defined processes for raising concerns and conducting learning reviews after inspections.
Addressed to: Department for Education; Ofsted; Reading Borough Council
AI-generated concerns summaryConcerns were raised about delays in hospital transfer, confusion over clinical leadership, and inadequate management of a nasogastric tube, leading to a fatal aspiration. The report also notes insufficient pain relief and a misunderstanding of the patient's acute needs.
Addressed to: University College London Hospitals NHS Trust
AI-generated concerns summaryThe coroner identified inadequate completion of observation charts and unclear staff responsibilities for their checking. Risk assessment policies also did not sufficiently incorporate historical and contextual information, including previous statements and attempts to end their life.
Addressed to: Devon Partnership NHS Trust; Langdon Hospital
AI-generated concerns summaryThe coroner noted delays in follow-up by the community mental health team and a lack of referral to the crisis team. Additionally, insufficient efforts were made to involve the patient's family in his mental health care, despite recognised therapeutic benefits.
Addressed to: South West London and St George’s Mental Health NHS Trust
AI-generated concerns summaryThe coroner identified inadequate community provision for autistic individuals, leading to unnecessary hospital admissions. There is an acute shortage of suitable placements and support services for these individuals.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted inadequate record-keeping and a lack of formal handover of a critical incident from critical care to the surgical team. This meant surgeons were unaware of a potential brain injury, which influenced treatment decisions and contributed to death.
Addressed to: University Hospital Plymouth NHS Trust
AI-generated concerns summaryThe coroner raised concerns about extensive waiting lists for Gender Identity Disorder clinics, insufficient local patient support, and unclear responsibility for wellbeing during this period. There was also a noted lack of specialist knowledge in local mental health services and clear guidance for GPs on bridging hormone prescriptions.
Addressed to: NHS England
AI-generated concerns summaryThe coroner raised concerns regarding inadequate information in discharge reports, a lack of updated risk assessments for changing patient presentation, and inconsistent review of medical notes. The report also described general poor record-keeping without an audit system.
Addressed to: Sheffield Health and Social Care Trust
AI-generated concerns summaryConcerns identified varied professional understanding of cyclizine and its easy over-the-counter purchase without sufficient checks. Also, a commissioned pathway was absent in Rochdale for community blood tests for compromised patients.
Addressed to: Greater Manchester Health and Social Care Partnership/Integrated Care Board; Medicines and Healthcare Products Regulatory Agency; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner identified that Mrs Aston was not appropriately categorised as a high-risk patient requiring immediate surgery at Kettering General Hospital, leading to a significant delay in life-saving intervention. The decision-making process for not operating at the hospital was unclear.
Addressed to: Kettering General Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about the lack of compulsory mountain flying training for PPL(A) licence holders in the UK and the absence of specific guidance for pilots navigating mountain passes. This includes no requirement for flying schools to provide such advice.
Addressed to: UK Civil Aviation Authority
AI-generated concerns summaryThe coroner noted the absence of a consistent joint operating protocol between police and ambulance services, leading to a lack of clarity regarding roles and how police can escalate concerns for individuals suspected of drug overdoses.
Addressed to: British Transport Police; Cheshire and Merseyside Integrated Care Board; Cheshire Constabulary; Cumbria Constabulary; Greater Manchester Integrated Care Board; Greater Manchester Police; Lancashire and South Cumbria Integrated Care Board; Lancashire Constabulary; Lancashire Fire and Rescue Service; Merseyside Fire and Rescue Service; Merseyside Police; North West Ambulance Service; North West Fire Control
AI-generated concerns summaryThe coroner identified concerns regarding the administration of a specific medication contributing to serotonin syndrome and death. There is a risk other NHS organisations may not fully appreciate these risks, particularly with complications common in overdose patients.
Addressed to: Intensive Care Medicine
AI-generated concerns summaryThe coroner noted a lack of awareness among hospital paediatric doctors regarding paramedic administration of intramuscular adrenaline for life-threatening asthma according to JRCALC protocol. Concerns were also raised about JRCALC guidelines lacking clarity for paramedics on managing severe asthma attacks.
Addressed to: Association of Ambulance Chief Executives; Department of Health and Social Care; East of England Ambulance Service NHS Trust; Essex Partnership University NHS Foundation Trust; Mid and South Essex NHS Foundation Trust