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 identified inadequate falls prevention measures, including incomplete referral forms and a lack of escalation despite numerous falls. Concerns also related to insufficient care for a resident with evolving dementia and a lack of staff training in falls prevention.
Addressed to: Abbey Wood Lodge Care Home
AI-generated concerns summaryThe Trust's policy lacked clarity on how nursing staff should escalate issues with external ventricular drains that stopped draining but still oscillated. There is no standard national policy addressing this specific risk, leading to variations across Trusts.
Addressed to: NHS England; NHS Improvement; Society of British Neurological Surgeons
AI-generated concerns summaryThe coroner identified a lack of specialist medical staff and clear guidelines for elderly hospital patients, alongside concerns about patient falls. Additionally, ambulance staff did not complete falls risk assessments or have adequate training regarding falls risks.
Addressed to: Bristol Ambulance Emergency Medical Services; Department of Health and Social Care; Royal United Hospitals Bath NHS Foundation Trust; South Western Ambulance Service NHS Foundation Trust
AI-generated concerns summaryInsufficient monitoring for signs of Pregabalin abuse was identified, particularly given the patient's known history of drug abuse. Concerns were also raised that a Serious Event Analysis exploring potential record-keeping and prescribing issues may not have fully explored relevant risks.
Addressed to: Limehouse Practice
AI-generated concerns summaryThe coroner noted a patient was not re-admitted to hospital despite indications, and an urgent psychiatric review referral was not acted upon. A Serious Incident Investigation Report identified gaps in assessment and risk documentation, but lacked a plan to address these issues.
Addressed to: Oxleas NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of information for prescribing doctors regarding the known interaction between tramadol and warfarin, as this interaction is not listed in the British National Formulary.
Addressed to: NHS England
AI-generated concerns summaryThe hospital's Venous Thromboembolism Prevention Policy did not include risk assessment for patients who attended but were not admitted, and no other policy covered this patient group.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner notes that a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases is absent, which experts stated would improve outcomes and survival rates.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner raises concerns about the insufficient English language proficiency of care workers, noting that the current B1 test level is inadequate for communicating effectively with emergency medical professionals when caring for vulnerable individuals.
Addressed to: Department of Health and Social Care; Home Office
AI-generated concerns summaryThe Shared Care Record (SCR) system does not automatically flag steroids, which can have fatal side effects if used long-term without monitoring. Additionally, the SCR lacks a field to record the clinical indication for drug initiation.
Addressed to: NHS England; NHS Improvement
AI-generated concerns summaryThe coroner identified a risk of future deaths in similar circumstances, noting that informing the public, particularly carers of children, could help reduce this risk.
Addressed to: Manchester City Council; UK Health Security Agency
AI-generated concerns summaryDerbyshire Constabulary officers' investigation of a stalking complaint showed serious failings, highlighting a need for improved knowledge and understanding of such investigations. Additionally, there was an insufficient understanding of completing comprehensive and regularly reassessed risk assessments.
Addressed to: Derbyshire Constabulary; Home Office
AI-generated concerns summaryThe coroner noted that the national NHS Pathways process does not differentiate between high-risk and low-risk overdoses, which risks delaying prompt treatment for individuals who have taken a potentially fatal overdose.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about patient notes not being consistently sent to external appointments from Queens Hospital, noting that no one person had responsibility for ensuring they were sent. This process risks critical information not being passed on if a patient is unable to provide a full medical history.
Addressed to: Queens Hospital; Royal London Hospital
AI-generated concerns summaryThe GP practice lacked a robust system for ensuring that critical incoming correspondence reached medical staff, and adverse medication markers were not consistently placed on computerised records, risking contraindicated prescriptions.
Addressed to: Croft Shifa Health Centre
AI-generated concerns summaryThe coroner noted a lack of effective communication between multi-disciplinary teams from different specialisms when a patient is on more than one treatment pathway.
Addressed to: Nottingham University Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted the absence of a routine mechanism to cross-reference prescribed and collected medication, and a lack of automatic notification to GPs when patients did not collect medication, particularly for those with suicidal ideation.
Addressed to: Barnet Enfield and Haringey Mental Health NHS Trust
AI-generated concerns summaryThe coroner identifies concerns regarding persistent, lengthy ambulance handover delays at Treliske and Derriford Hospitals, which significantly affect ambulance response times in the SWAST region. These delays mean patients still experience extended waits in ambulances, despite introduced measures.
Addressed to: Department of Health and Social Care
AI-generated concerns summarySFRS lacks a system for reviewing or auditing Safe and Well Visits, especially those conducted by inexperienced officers, which can lead to missed issues. Additionally, ASC has insufficient systems for oversight to ensure that risk assessments are carried out after appropriate visits.
Addressed to: Surrey County Council
AI-generated concerns summaryThe coroner noted slow progress in improving the management of patients with food intolerances/allergies, and a lack of investigation into a specific gluten ingestion incident. Concerns were also raised about insufficient Datix reporting for similar incidents and staff awareness of reporting procedures.
Addressed to: Betsi Cadwaladr University Health Board