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 that a community public access defibrillator was supplied in a non-workable condition, pointing to a lack of system for pad replacement and a staff training or communication issue. Concerns were also raised about the absence of a clear national system for maintaining defibrillators and sharing their operational …
Addressed to: Central England Co-operative; Department of Health and Social Care
AI-generated concerns summaryFrome Nursing Home staff did not adequately assess or manage the risk of deep vein thrombosis for an immobile patient, lacking a DVT policy and failing to inquire about care needs or implement preventative measures.
Addressed to: Frome Nursing Home
AI-generated concerns summaryThe coroner noted that DWP procedures, including the length and number of forms, long telephone queues, and extensive travel for appointments, may not be practical for individuals with mental health illness and could exacerbate their symptoms.
Addressed to: Department for Work and Pensions
AI-generated concerns summaryThe coroner identified serious deficiencies impacting patient safety at Southmead Hospital and noted that the CQC should confirm the Trust has addressed both current and ongoing staff training.
Addressed to: Care Quality Commission; North Bristol NHS Trust
AI-generated concerns summaryThe coroner raises concerns that ice hockey players over 18 are not required to wear neck guards, despite International Ice Hockey Federation recommendations, potentially risking future deaths.
Addressed to: Elite Ice Hockey League; English Ice Hockey; Horwich Farrelly Limited; Ice Hockey UK
AI-generated concerns summaryThe coroner identified a lack of health and safety procedures for jet ski hire, including no instructions on emergency cut-off, avoiding dangerous areas, or the provision of lifejackets. Additionally, Foreign, Commonwealth and Development Office travel advice does not explicitly state that safety standards may be lower than in the UK.
Addressed to: Consular Feedback Team
AI-generated concerns summaryThe coroner identified a lack of awareness and compliance with St. Andrew's Healthcare's Pressure Ulcer Prevention and Management Policy, including inadequate assessments, skin inspections, and incident reporting. Concerns were also raised about the organisation's governance and quality assurance processes, which failed to identify these issues prior to the inquest.
Addressed to: St Andrews Healthcare
AI-generated concerns summaryMissed opportunities to engage with Mr Huber for risk and needs assessment, alongside the absence of multi-agency and multi-disciplinary discussions to address his situation.
Addressed to: Devon County Council
AI-generated concerns summaryThe mental health liaison nurse lacked direct access to hospital records, leading to an assessment without critical information about a patient's command hallucinations and self-harm thoughts. This gap in record sharing between services may affect future patient safety.
Addressed to: Birmingham and Solihull Mental Health NHS Foundation Trust; Sandwell and West Birmingham NHS Trust
AI-generated concerns summaryThe Cleric computer system used by the North East Ambulance Service prevented clinicians from upgrading ambulance response categories due to a locking facility that precluded access during live calls, even as a patient's condition deteriorated.
Addressed to: Cleric
AI-generated concerns summaryThe coroner notes concerns that the risk of cognitively impaired residents operating riser-recliner chairs, potentially harming others, is not consistently foreseen or mitigated in care homes. There is also a lack of manufacturing standards for 'safe' remote controls on such chairs.
Addressed to: Care Quality Commission; Department of Health and Social Care; Health and Safety Executive
AI-generated concerns summaryThe coroner identified unsafe clinical practices at HMP Lowdham Grange, including observations via cell door hatches, non-utilisation of the NEWS2 system, and insufficient robust GP visits. A lack of effective healthcare leadership was also noted.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe emergency department at Northwick Park Hospital did not elicit Mr Bailey's recent smoking history or family history of ischaemic heart disease, information that would have triggered a rapid access chest pain clinic referral.
Addressed to: Church Lane Surgery; Northwick Park Hospital
AI-generated concerns summaryConcerns included incomplete food and fluid charts and observations not taken hourly or fully logged in care records. Emergency services were not called for a high NEWS2 score, and 111 call takers were not informed of it.
Addressed to: Amberley Hall Care Home; Athena Care Homes (UK) Limited
AI-generated concerns summaryThe coroner raises concerns about the Oxford Trust's approach to learning from deaths, noting a lack of investigation, no recorded meeting minutes, and an absence of proposed changes following Mr Barnes' death. The trust also did not cooperate with other hospitals for a joint investigation.
Addressed to: Oxford University Hospitals NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clarity regarding responsibilities for VTE risk assessments when patients are discharged from hospital to community settings, leading to potential assessment gaps. Additionally, pathways for community organisations to become aware of relevant NICE guidance were unclear.
Addressed to: National Institute for Health and Care Excellence
AI-generated concerns summaryVirgin Care's non-adoption of the NHS England standard for clinical assessment within 15 minutes raises concerns about future deaths. Additionally, gaps were noted in transcribing and preserving patient-provided information, impacting clinical review and incident investigation.
Addressed to: Coventry and Rugby Clinical Commissioning Group; Virgin care Coventry LLP
AI-generated concerns summaryThe coroner raises concerns about the CQC's approval of a walk-in centre's triage process, which was judged to be clinically need-based but did not include taking clinical observations, a standard practice in secondary care hospitals.
Addressed to: Care Quality Commission; Coventry and Rugby Clinical Commissioning Group; Urgent Care NHS England; Virgin care Coventry LLP
AI-generated concerns summaryThe coroner noted that relying solely on ultrasonography without CT scanning prior to hysterectomy could lead to future missed diagnoses of uterine sarcoma.
Addressed to: Royal Free London NHS Foundation Trust
AI-generated concerns summaryRelevant patient information was stored in disparate record systems, making it difficult for clinicians, especially psychiatric teams, to access critical details. The coroner noted this poses risks due to the current state of record sharing within the NHS.
Addressed to: National Institute for Health Care Excellence