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 deficiencies in the mental health referral process, including a lack of identified suicide risk and insufficient multi-team discussion at screening meetings. Concerns also included a lack of direct patient contact, poor record-keeping, and the absence of standard operating procedures and audit for referrals.
Addressed to: Pennine Care NHS Foundation Trust
AI-generated concerns summaryThe coroner identified an ongoing and inadequate lack of psychiatric bed capacity in Birmingham and Solihull, noting that previous actions had been insufficient to resolve the problem. This situation, coupled with an unsatisfactory exceptional process for bed provision, poses a genuine risk of future deaths.
Addressed to: Birmingham and Solihull Mental Health Foundation Trust; Department of Health and Social Care; NHS Birmingham and Solihull Integrated Care Board
AI-generated concerns summaryThe coroner noted a resurgence of ambulances queuing outside the ED, with 15-20 waiting on occasions. Additionally, concerns were raised about 'burn-out' among healthcare staff and difficulties in recruiting to vacant positions.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raises concerns that critical offender information was not clearly recorded or easily accessible in Probation Service records, impacting risk assessment. Domestic abuse and child safeguarding checks were also insufficient or lacking, posing ongoing risks.
Addressed to: Capita; Chief Probation Officer for England and Wales; Derbyshire Healthcare NHS Foundation Trust; Secretary of State for Justice
AI-generated concerns summaryThe coroner noted an omission to update the Hospital Overview correctly and timeously, and a lack of documentation regarding discussions about patient repatriation to an available bed.
Addressed to: Dorset Healthcare University NHS Foundation Trust
AI-generated concerns summaryA nationwide shortage of trained cardiologists means District General Hospitals lack out-of-hours, in-person assessment for suspected cardiac problems, relying instead on non-specialist staff and often impractical transfers.
Addressed to: Department of Health and Social Care; NHS England; Royal College of Physicians
AI-generated concerns summaryThe coroner noted several missed planned patient visits due to the absence of a Care Coordinator and no appointment of interim cover. Concerns were raised about the lack of responsibility for a Duty officer to review appointments during absences and the absence of resilience plans for staff absences.
Addressed to: Greater Manchester mental Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that information about a patient's severe side pain was not fully communicated to the Advanced Nurse Practitioner. Concerns were raised regarding the scope of staff training on managing and escalating chest or abdominal pain reports, particularly for at-risk patients.
Addressed to: National Institute for Health and Care Excellence; Old Bridge Surgery
AI-generated concerns summaryThe coroner noted a four-day delay in surgery due to NHS-wide understaffing and underfunding, with wards combining elective and emergency work. Patients injured on a Friday faced disadvantages due to limited weekend staffing and experience.
Addressed to: NHS England; Royal Stoke University Hospital
AI-generated concerns summaryPolice training on Acute Behavioural Disturbance (ABD) focused rigidly on specific symptoms, potentially causing officers to miss nuanced signs of drug-induced ABD and the associated risks of prone restraint. There was also a noted absence of training on calming de-escalation for individuals under the influence of stimulant drugs.
Addressed to: College of Policing; National Police Chiefs Council
AI-generated concerns summaryThe coroner noted insufficient staff compliance with ACCT procedures for recording risk factors, and concerns regarding the quality of ACCT training and audits. Information sharing between prison and healthcare staff was also identified as problematic due to separate record systems.
Addressed to: HM Prison and Probation Service
AI-generated concerns summaryThe coroner noted a lack of provision for Thrombectomy Service after 5pm in Lancashire and that neighbouring Trusts cannot accept patients, raising concerns about access to this urgent treatment.
Addressed to: NHS England
AI-generated concerns summaryThe Badgernet electronic system's risk assessment at Royal Victoria Infirmary does not fully map national guidance, affecting effective and safe assessment. The NEWTT2 chart, intended for risk management, is also not yet implemented on BadgerNet.
Addressed to: Clevermed Limited
AI-generated concerns summaryThe coroner noted that current regulations for sideguards on extendable heavy goods vehicles may not adequately protect road users when trailers are extended, creating a significant gap in protection compared to fixed trailers.
Addressed to: Department for Transport
AI-generated concerns summaryThe coroner identified issues with the initial falls risk assessment not utilising all available information and a lack of flexibility and resilience in staffing to provide enhanced supervision for vulnerable patients, especially during night shifts.
Addressed to: Department of Health and Social Care; Great Western Hospital
AI-generated concerns summaryThe coroner noted a lack of guidance and protocols for paramedics and ambulance staff regarding the appropriate duration of resuscitation and when to transport a patient to hospital for thrombolysis.
Addressed to: Association of Ambulance Chief Executives; Yorkshire Ambulance Service
AI-generated concerns summaryHealth visitors are not consistently conducting physical reviews of sleeping arrangements for babies under 6 weeks, as required by guidance. This means opportunities are missed to risk assess co-sleeping and advise parents.
Addressed to: Cardiff and Vale University Health Board
AI-generated concerns summaryThe coroner identified that paramedics incorrectly interpreted an abnormal ECG, failing to recognise key indicators of a cardiac event, and provided the patient with incorrect information. Concerns were raised regarding the effectiveness and qualitative assessment of ECG interpretation training for paramedics.
Addressed to: Health & Care Professions Council; HSIB; Quality Care Commission; West Midlands Ambulance Service University NHS Foundation Trust; Wolverhampton University
AI-generated concerns summaryThe coroner noted continuing and regular instances of ambulance non-availability in Suffolk and the East of England, causing attendance times to fall short of targets. There are concerns this insufficient ambulance resource could lead to future loss of life.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about the national availability of Tier 4 beds in paediatric mental health facilities, impacting the timely allocation of care for children needing such services.
Addressed to: NHS England