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 Trust's Rapid Tranquilisation policy was not sufficiently embedded or clear regarding post-sedation monitoring, especially for sleeping patients, and appeared to diverge from national NICE guidance. There was also a lack of guidance on managing Psychogenic Polydipsia.
Addressed to: Nottinghamshire Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted that seatbelts were not used by students or the driver on a school commuter coach. Concerns were raised regarding the lack of clear government advice to schools on seatbelt use for such contracts and the absence of public information campaigns promoting seatbelt safety.
Addressed to: Department for Education; Department for Transport
AI-generated concerns summaryThe coroner noted that the deceased received duplicate prescriptions for the same medication from both a GP and the hospital, which she then used to end her life. Concerns were raised about the absence of checks to prevent such duplicity in prescriptions between primary and secondary care.
Addressed to: United Lincolnshire Hospitals NHS Trust
AI-generated concerns summaryThe coroner raised concerns about police officers having limited access to readily available, clinically qualified mental health advice and patient records after the withdrawal of triage support, with no clear timeline for the intended replacement service.
Addressed to: South Wales Police
AI-generated concerns summaryThe coroner identified that no suicide or self-harm risk assessment was conducted upon release from detention, and communication with the Police regarding any assessment was unclear. Additionally, documentation used misleading terminology about unmet needs, and an internal review lacked comment or identification of learning areas.
Addressed to: Midlands Partnership NHS Foundation Trust
Addressed to: Greater Manchester Mental Health NHS Foundation Trust; NHS England
AI-generated concerns summaryThe coroner notes limited regulation and oversight for businesses offering led cold water immersion sessions. Concerns include a lack of specific health and safety guidance, unclear monitoring responsibilities, and no established standards for leader training or participant safety.
Addressed to: Health and Safety Executive
AI-generated concerns summaryThe coroner noted a lack of consistency in staff providing Mr Donoghue's care, identifying that continuity of staff within the Home Based Treatment Team (HBTT) system is affected by insufficient funding, recruitment, and retention.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryConcerns were raised regarding the deployment of Custodial Nurse Practitioners in police custody without adequate mental health training for high-risk detainees. There were also identified gaps in ACCT process training for agency healthcare staff working in prisons.
Addressed to: Home Office; National Police Chief’s Council; NHS England
AI-generated concerns summaryThe coroner identified concerns regarding the late notification of immigration detention decisions, insufficient signposting of legal advice entitlements for Foreign National Offenders, and communication issues between agencies involved in immigration and sentence planning.
Addressed to: HMP Belmarsh; HM Prison and Probation Service; Home Office; Ministry of Justice; Practice Plus Group
AI-generated concerns summaryThe coroner noted ongoing issues at Birmingham & Solihull Mental Health NHS Foundation Trust with risk assessments not being properly completed or updated, raising concerns about insufficient recording of risk. A task and finish group addressing this is in its early stages, and there is no evidence the issues have …
Addressed to: Birmingham and Solihull Mental Health Foundation
AI-generated concerns summaryThe lorry tyre boundary wall did not adequately absorb energy, and available impact-absorbing protection was not utilised, with decisions failing to account for racer error. There was insufficient consideration of wet grass conditions, which affected the kart's movement, and the risk assessment for racing in wet weather needs urgent review.
Addressed to: Addressees have not been indexed.
AI-generated concerns summaryThe coroner noted a lack of awareness among patients and specialist clinicians about the risk of lung damage from Nitrofurantoin. Concerns were raised about the effectiveness of existing guidance for prescribers and patients on vigilance for symptoms like coughing or breathlessness.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted significant delays in ambulance response times, with one patient waiting over 19 hours for a Category 3 call. There were also considerable delays for A&E admission after ambulance arrival due to hospital pressure.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryThe coroner noted an endemic problem of illicit substance use within SAH, raising concerns that this risk is not being adequately mitigated. This situation poses a significant risk to vulnerable patients in the secure hospital environment.
Addressed to: Care Quality Commission; St Andrew’s Healthcare; West Midlands Police
AI-generated concerns summaryDelays in diagnosis, treatment, and care escalation, alongside fragmented care across two Trust sites, probably increased the risk of biliary sepsis due to an unclear treatment pathway.
Addressed to: Barking, Havering and Redbridge University Trust
AI-generated concerns summaryThe coroner notes that East Surrey Hospital's inability to perform hip fracture operations within the NICE guideline timeframe (on the day of admission or the day thereafter) places patients at increased risk of complications and early death.
Addressed to: Surrey and Sussex Healthcare NHS Trust
AI-generated concerns summaryThe coroner identified concerns about the reliability, suitability, and ease of use of SATS machines provided for home monitoring, particularly after one machine ceased to function and alarms from another device were not responded to.
Addressed to: Berkshire Integrated Care Board; Medication and Healthcare Products Regulatory Agency; Medtronic; NHS England; Royal Berkshire NHS Foundation Trust
AI-generated concerns summaryThe coroner highlighted that radiologists lack direct access to full patient medical notes, relying on potentially deficient summaries, and identified overall poor and misleading communication between clinicians and departments.
Addressed to: North Cumbria Integrated Care NHS Foundation Trust
AI-generated concerns summaryThe hospital discharge summary was ambiguous regarding Mr. Brooks' target fluid intake, which led nursing home staff to misinterpret his needs. Consequently, his fluid intake target was not met.
Addressed to: Royal Devon University Healthcare Foundation Trust