Bedfordshire and Luton
Coroner Area
Reports: 80
Earliest: Jan 2014
Latest: 19 Mar 2026
79% response rate (above 63% average).
Terence Fernandes
Partially Responded
2014-0220
12 May 2014
Association of Train Operating Companies
Department for Transport
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.
Action Planned
(AI summary)
ATOC has been directed by the Council to write to its members to explicitly alert them to the circumstances of the death and suggest that they consider whether any changes should be made to the first aid arrangements and the importance of the recovery position. ATOC will facilitate a further discussion on first aid provision amongst the TOCs at the next Safety Forum.
Ernest Harper
All Responded
2014-0223
9 May 2014
Bedford Borough Council
Other related deaths
Concerns summary (AI summary)
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Action Taken
(AI summary)
Bedford Borough Council has retro-fitted devices to block gaps on Ford Transit vehicles. A new assessment form designed with Occupational Therapists will be introduced by July 14, 2014, and a client-specific risk assessment will be conducted for non-ambulant clients. A written form has been produced to ensure information regarding the client is also provided in a written format.
Gianna Khan
All Responded
2014-0219
9 May 2014
Bedfordshire Clinical Commissioning Gro…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by a doctor in the A&E Department, and that the Clinical Commissioning Group had refused a full triage before streaming patients.
Action Planned
(AI summary)
Luton CCG will share findings with Luton Clinical Commissioning Group, LHS has accepted NICE Guidance CG176, LHS will cooperate with NHS England investigation and is resubmitting its 'Risk and Serious Incident Framework' for scrutiny, key priority will be review of emergency and urgent care commissioning arrangements.
Sari Keen
All Responded
2014-0180
16 Apr 2014
Luton and Dunstable University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Action Taken
(AI summary)
Luton & Dunstable University Hospital has increased night nursing staff on ward 22 following a staffing review. The hospital is evaluating current training for nurses and doctors, and will present the case at safety meetings to share learning.
Albert James Hand
All Responded
2014-0010
9 Jan 2014
East of England Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Action Taken
(AI summary)
The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided Dispatch (CAD) system. They are also continuing to augment their clinical coordination function within the Health and Emergency Operations Centres (HEOCs).