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 summaryConcerns are raised that patients travelling abroad for autologous fat transfer (Brazilian Buttock Lift) procedures are unaware of the high mortality risk and undergo surgery with insufficient pre-operative assessment and regulatory controls.
Addressed to: Department of Health and Social Care
AI-generated concerns summaryHeavy goods vehicles are permitted to stop and unload on a particular stretch of road, thereby blocking the southbound carriageway.
Addressed to: Hertfordshire County Council
AI-generated concerns summaryThe coroner noted that Mrs Kramer was prescribed Zopiclone, a short-term medication, for 18 years without clear evidence of review by her GP or mental health trust, even following instances of high-risk behaviour.
Addressed to: Department of Health and Social Care; North East London Foundation Trust; Wood Street Medical Centre
AI-generated concerns summaryThe coroner noted considerable and continuing delays in ambulance response times, with one patient waiting over 14 hours, attributed to very high call demand and significant pressure on the healthcare system, including hospital handover delays.
Addressed to: Department of Health and Social Care; East of England Ambulance Service NHS Trust; Spire
AI-generated concerns summaryThe coroner noted a risk of delayed or missed antibiotic treatment for newborns due to conflicting guidance between the Kaiser Permanente Score and NICE recommendations. This conflict creates potential confusion for medical staff in other neonatal units and risks avoidable delays in care.
Addressed to: British Association Perinatal Medicine; NHS England; Queen Elizabeth Hospital Trust; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe Medical Priority Dispatch System's advice for varicose vein bleeds was not consistently provided due to human error, and there was no evidence of the effectiveness of staff reminders to prevent this.
Addressed to: Welsh Ambulance Services NHS Trust
AI-generated concerns summaryThe provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
Addressed to: University Hospitals Bristol; Weston NHS Foundation Trust
AI-generated concerns summaryDisjointed governance processes and slow action completion hinder effective learning from incidents. Fragmented paper-based medical records also risk incomplete information sharing and affect continuity of care for mental health patients.
Addressed to: Barts Health NHS Foundation Trust
AI-generated concerns summaryThe coroner noted a lack of awareness among clinicians at University Hospitals Birmingham regarding Myasthenia Gravis and its interaction with Gentamicin. There is concern this lack of awareness could exist more widely across the country.
Addressed to: NHS England
AI-generated concerns summaryThe coroner identified a failure to diagnose an ongoing renal haemorrhage despite clear clinical indicators and the administration of VTE prophylaxis while the patient had a patent bleed. Additionally, inadequate monitoring during admission allowed the patient's condition to deteriorate preventably.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner raised concerns about continued pressures within the Accident and Emergency department at Ysbyty Gwynedd, potentially leading to doctors missing target review times for patients and insufficient staffing levels to safely meet demand.
Addressed to: Betsi Cadwaladr University Health Board
AI-generated concerns summaryThe coroner identified an inadequate falls prevention policy, unlocked doors to unoccupied rooms, night lights not being on in common areas, and insufficient periodic nightly observations.
Addressed to: Phoenix Care Centre
AI-generated concerns summaryGuidance on prescribing fluoxetine does not indicate routine blood testing for drug levels during palpitations. The coroner requested a review of this guidance to consider when such tests are advisable.
Addressed to: British National Formulary; National Institute for Health and Care Excellence
AI-generated concerns summaryThe health tourism company relied on patient self-declaration for surgical fitness, lacking independent assessment or clear questions. The coroner also noted no investigation into the operating table death, discrepancies in medical documentation, and inadequate embalming for repatriation.
Addressed to: Regenesis Health Travel Limited
AI-generated concerns summaryEmergency departments operating under OPEL 4 conditions can impede patient triage and communication, risking patient safety and care standards. A lack of realistic GP information on ED waiting times may also delay patients seeking assistance.
Addressed to: Department of Health and Social Care; Lancashire and South Cumbria Integrated Care Board
AI-generated concerns summaryThe coroner noted a lack of meaningful steps to escalate Ms Levy's care despite her deteriorating health and self-neglect, with no formal Mental Capacity Act assessment or mental health referral undertaken. Concerns were also raised about a flawed Serious Investigation decision by the Trust, which underestimated the seriousness of her …
Addressed to: Department of Health and Social Care; London Borough of Redbridge Council; North East London Foundation Trust
AI-generated concerns summaryConcerns were raised regarding the absence of a formal process for officers to proactively assess an individual's mental health and risk of self-harm or suicide at the point of charge, especially when communicated without advance warning.
Addressed to: College of Policing; Metropolitan Police Service
AI-generated concerns summaryThe coroner raises concerns about significant under-resourcing of CAMHS, leading to delays in assessment, a lack of consultant psychiatrist leadership, and insufficient funding, amidst increasing demand.
Addressed to: Department of Health and Social Care; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted inconsistencies in record keeping between hospital specialties, an inadequate process for flagging handwritten notes in the digital system, and the absence of an alert for reviewing suspended medications in the electronic prescribing system.
Addressed to: Royal Cornwall Hospital Trust
AI-generated concerns summaryThe coroner expressed concern that the self-certification process for driving licenses for individuals aged 70 and over lacks independent medical scrutiny of cognitive ability. This absence of checks creates a risk of future deaths from drivers with undiagnosed conditions affecting hazard perception.
Addressed to: Cambridge County Council; Department for Transport