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 that self-discharge procedures at Atherleigh Park Hospital lack a consultant review for potential Mental Health Act detention and a checklist for junior doctors. Additionally, no medication was prescribed or dispensed upon self-discharge.
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
AI-generated concerns summaryEmergency medicine guidelines lack sufficient guidance to raise the profile of acute aortic dissection when chest pain radiates to the throat and jaw. Delays in radiologist review of chest x-rays, due to a national shortage, create an ongoing risk in emergency situations.
Addressed to: NHS England; Royal College of Emergency Medicine; Royal College of Radiologists
AI-generated concerns summaryThe coroner identified gaps in police training for recognising Acute Behaviour Disturbance (ABD) and assessing its knowledge. Concerns also included the non-recognition of a safety officer role and officers relying on subjective assessments instead of objective AVPU checks for unresponsiveness.
Addressed to: College of Policing; National Police Chiefs Council
AI-generated concerns summaryThe coroner identified a lack of mandatory induction training for out-of-hours GPs at Vocare, with no online option available. There was also confusion among staff regarding the functionality of call centre systems.
Addressed to: Totally Urgent Care
AI-generated concerns summaryThe coroner noted that emergency department discharge summaries did not clearly identify actions required by GPs, and an audit showed deficiencies. Concerns were also raised that Southern Health staff are not permitted to take blood samples for clozapine patients' annual physical health checks, leading to missed appointments.
Addressed to: Hampshire Hospitals NHS Foundation Trust; Southern Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of clear policy for communicating drug alerts to patients when a GP prescribes medication at the behest of a non-prescribing mental health practitioner without direct patient contact. There was also ambiguity regarding ultimate responsibility for ensuring patients receive relevant drug information in these circumstances.
Addressed to: Lister House Oakwood
AI-generated concerns summaryThe coroner noted that the blood gas analyser was not set to analyse haemoglobin level at birth, preventing consideration of other possible causes for a baby's condition. There is a lack of clarity and inconsistent national practice regarding this, raising a risk of preventable deaths.
Addressed to: National Institution for Health and Care Excellence; Royal College of Obstetricians and Gynaecologists; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted a lack of guidance for monitoring self-administered medication for patients who do not take it immediately, despite policies stating medication should not be left at the bedside.
Addressed to: University Hospitals Sussex NHS Foundation Trust
AI-generated concerns summaryThe coroner noted concerns about the careless completion of a cell sharing risk assessment and the surprisingly low level of first aid understanding among some HMP Pentonville officers. There was also a lack of confirmed guidance for prisoners on how to assist cellmates experiencing a fit.
Addressed to: HM Prison Pentonville; Practice Plus Group
AI-generated concerns summaryThe report describes inconsistent and inaccurately recorded observations for prisoners on suicide and self-harm prevention procedures, with some officers misinterpreting timing rules. Additionally, prison officers were noted to work excessively long hours.
Addressed to: Exeter Prison
AI-generated concerns summaryThe coroner raised concerns regarding HMP Aylesbury's recruitment and retention of experienced prison staff following its transition to a Category C prison. This impacts daily operations, training, and incident response amidst a changing prisoner cohort with increased violence and substance access.
Addressed to: Prison and Probation Service
AI-generated concerns summaryThe coroner identified an inadequate assessment of a child's severe illness and the failure to seek a second medical opinion, despite the mother's clear concerns about deterioration. This reflects a pattern where parental observations do not lead to appropriate care escalation.
Addressed to: Department of Health and Social Care; NHS England
AI-generated concerns summaryThe coroner noted a lack of specific national guidance on prescribing antiviral medication for Herpes Simplex in post-partum women with systemic infection, and insufficient awareness of it as a potential diagnosis in sepsis pathways.
Addressed to: NHS England; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryClinical staff at SMH lack routine access to patients' Summary Care Records, which are not integrated with the hospital's electronic patient record system. This absence of critical patient information means doctors may be unaware of important details, such as allergies.
Addressed to: North Bristol NHS Trust
AI-generated concerns summaryBluebird Care did not communicate with the new care provider, Divine Health Services Ltd., regarding Mr. Friend's needs or concerns about a hoist sling when his care transferred.
Addressed to: Bluebird Care; Divine Health Services; Herefordshire and Worcestershire Health and Care NHS Trust
AI-generated concerns summaryThe coroner raises concerns that Worcestershire Regulatory Services' Licensing Team does not proactively monitor websites for unlicensed dog breeders, relying solely on intelligence. This approach allows unlicensed breeders to operate, which presents a heightened risk of danger from dogs sold in the area.
Addressed to: Wychavon District Council
AI-generated concerns summaryConcerns include the failure to identify risk factors in high-risk pregnancies, leading to insufficient consideration of elective Caesarean Sections. The coroner also noted gaps in training and escalation processes for junior doctors regarding appropriate mode and timing of birth decisions.
Addressed to: Department of Health and Social Care; George Eliot Hospital NHS Trust; National Institute for Health and Care Excellence; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists
AI-generated concerns summaryThe Health Board's investigation into the transfer of care was deficient, and its transfer of care policy remained unfinalised and not widely shared. Mental health patient notes are still paper-based, with no anticipated timescale for electronic implementation.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner noted a lack of awareness regarding cold water shock, water rescue procedures, and the risks of handcuffing near water, along with insufficient dissemination of the Hampshire Constabulary's "Working near Water Procedure" and its risk assessments.
Addressed to: Hampshire & Isle of Wight Constubulary
AI-generated concerns summaryThe coroner identified persistent issues with the widespread availability of illicit drugs, including synthetic cannabinoids, at HMP The Mount. Reports from inspections and monitoring boards consistently noted weak drug supply reduction efforts and easy access to substances, impacting prisoner safety.
Addressed to: HMP The Mount; Ministry of Justice