Browse 6,470 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
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AI-generated concerns summaryThe coroner noted repeated incorrect documentation of medication adherence in the Rio notes, where medication refused by the patient was recorded as taken due to a breakdown in communication among staff. This poses a risk if staff believe medication has been administered when it has not.
Addressed to: St Andrew’s Healthcare
AI-generated concerns summaryThe coroner noted limited risk assessment and risk management planning for the patient, an inadequate system for monitoring patient returns from unescorted leave, and insufficient family involvement in care. There was also limited staff awareness of the ligature risk reduction pathway.
Addressed to: Nottinghamshire Healthcare NHS Foundation Trust
AI-generated concerns summaryThe coroner noted significantly increased waiting times for gastroenterology and gynaecology appointments in the NHS post-Covid, which are leading to delays in diagnosis and treatment across England.
Addressed to: NHS England
AI-generated concerns summaryA lack of suitable care beds resulted in a patient with dementia's unnecessary acute hospital stay. Insufficient information sharing between authorities and care homes meant safeguarding risks from an unsuitable resident placement were not recognised.
Addressed to: Greater Manchester Integrated Care
AI-generated concerns summaryThe coroner identifies a risk of future deaths due to the lack of regulation for counsellors in England and Wales, which includes no requirements for training, record-keeping, or reporting self-harm risks.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted concerns about a patient being discharged without their dalteparin prescription and the possibility that the last in-hospital dose was not given. This gap in anticoagulation may have significantly contributed to the development of a pulmonary embolism.
Addressed to: Hull and East Yorkshire NHS Trust
AI-generated concerns summaryThe coroner noted a lack of reasonable adjustments for Ms Twinn's disability during clinical decision-making and a lack of specialised learning disability nursing support for communication. Concerns also included unrecorded discharge decisions, absence of safety-netting advice for carers, and a delay in reporting a chest x-ray.
Addressed to: Bart Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner noted substantial and repeated delays in the completion of a serious incident investigation by the Trust, significantly exceeding the NHS framework's 60-working-day timescale. These delays impede the timely identification of system weaknesses to prevent future deaths.
Addressed to: Care Quality Commission; Tees, Esk and Wear Valleys NHS
AI-generated concerns summaryThe coroner raised concerns regarding the lack of suitable emergency social care placements in Stockport. This led to Mr Hall's hospital admission and subsequent rapid deterioration, as his needs could have been met more appropriately in a social care setting.
Addressed to: One Stockport Health and Care Board
AI-generated concerns summaryThe coroner raises concerns regarding the Metropolitan Police Service's (MPS) water rescue equipment for officers on patrol, the policies and training for cycle patrols near bodies of water, and awareness of dive team availability.
Addressed to: Metropolitan Police Service
AI-generated concerns summaryThe coroner noted that the school did not refer a student to NHS mental health services due to perceived long waiting lists, instead providing privately procured support with an unclear allocation process. There was also no clear communication process between the school and the private provider.
Addressed to: Department for Education; Department of Health and Social Care
AI-generated concerns summaryThe coroner is concerned that adult social care staff lack the tools, training, and guidance to recognise and act upon signs of eating disorders, which may delay urgent medical assessment and treatment for vulnerable individuals.
Addressed to: Blackpool Council
AI-generated concerns summaryThe coroner noted a lack of warnings from the UK tour operator about the risks of swimming and snorkelling in the sea off Malta for weak swimmers. The report suggests tour operators adopt a more proactive approach to highlighting such risks and mitigation strategies.
Addressed to: ABTA – The Travel Association; Foreign, Commonwealth and Development Office
AI-generated concerns summaryPoor communication and information sharing between agencies led to uncoordinated care and no clear overview of needs. Agencies did not fully recognise the individual's health issues and their interrelationship with social care and learning disability needs, affecting capacity assessments.
Addressed to: One Stockport Health and Care Board
AI-generated concerns summaryThe coroner identified gaps in junior staff's knowledge of escalation and chickenpox complications, alongside issues with clinical guidance on reinfection and assessment of skin lesions. The processing of GP referrals not following standard routes was also a concern.
Addressed to: Sheffield Children’s NHS Foundation Trust
AI-generated concerns summaryThe coroner noted unsustainable pressure on emergency department clinicians and staff, frequently operating at high escalation levels, which risks treatment delays and deaths. Concerns were raised about insufficient strategic planning and support to alleviate these pressures.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner raised concerns about the absence of an agreed protocol and specified timescales for police to inform suspects when a decision is made to take no further action on allegations against them, noting this gap could lead to further self-inflicted deaths.
Addressed to: Cheshire Police; National College of Policing; National Police Chief’s Council
AI-generated concerns summaryPoor clinical record keeping hampered governance processes, and a falls risk assessment and care plan were not completed, suggesting staff did not read essential patient records.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe DVT risk assessment in the Emergency Department at The Great Western Hospital did not account for lower limb immobility caused by plastic boots when considering anti-clotting medication. This gap could result in other patients developing deep vein thrombosis leading to pulmonary embolus.
Addressed to: Great Western Hospital
AI-generated concerns summaryConcerns included incomplete triage documentation and a promised follow-up call not being made. The triage doctor lacked awareness of appointment waiting times and relevant call transcripts, and a revised protocol for mental health patient triage had not been implemented.
Addressed to: Hereford Medical Group