Birmingham and Solihull

Coroner Area
Reports: 192 Earliest: Sep 2013 Latest: 14 Apr 2026

88% response rate (above 63% average).

Response Status
Responded 169 Historic 22 Pending 1
AI Classification
Action Taken 44%
Action Planned 33%
Noted 22%
Disputed 1%
Based on 299 classified responses
Top Categories
Hospital Death (Clinical Procedure… (69) Mental Health related deaths (29) Suicide (from 2015) (27) Care Home Health related deaths (23) Other related deaths (20)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: +118 reports · +24pp response rate
vs national average: +108 reports · +25pp response rate
192 results
Exauce Paoulen
All Responded
2016-0452 16 Dec 2016
Highways Department Birmingham City Cou…
Road (Highways Safety) related deaths
Concerns summary (AI summary) Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant risks to pedestrians, especially children.
Action Planned (AI summary) Birmingham City Council will develop and consult on road safety improvements along Grove Lane, with implementation planned for 2017/18 and aspiration for completion by July 2017.
Rex Hall
All Responded
2016-0422 29 Nov 2016
Health and Care Professions Council
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.
Action Taken (AI summary) The HCPC raised the threshold level of entry to the Register to degree level for paramedics, due to consultation feedback and the need for degree level education and training to deliver the Standards of proficiency to the depth required for contemporary paramedic practice. They are currently undertaking a review of the SOPs and will liaise with the College of Paramedics on the concerns raised in your report to explore whether any amendments should be made in this regard.
Timothy Jones
Partially Responded
2016-0421 24 Nov 2016
Bright and Hove Clinical Commissioning … Pavillions Richmond Medical Centre +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.
Action Planned (AI summary) The CCG will send a communication and learning alert to all Solihull member practices highlighting concerns and learning in relation to recording requests for home visits, GP home visit policies, and classifications of administrative tasks. The CCG will ask the Local Medical Committee to discuss with its members the consideration of a Solihull wide home visiting policy and the BAAG to consider the inclusion of aspiration pneumonia within the local version of the Primary Care Guidelines.
Alfie Rose
All Responded
2016-0382 26 Oct 2016
Dudley Group of Hospitals NHS Foundatio… University Hospitals Birmingham NHS Tru…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.
Action Planned (AI summary) Following meetings between the hospitals involved, actions have been agreed to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action table is attached. Following meetings between the hospitals involved, a detailed action plan has been developed and commenced to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action plan is attached.
Jane Reason
All Responded
2016-0376 25 Oct 2016
British Heart Foundation Department for Education Department of Health and Social Care +3 more
Other related deaths
Concerns summary (AI summary) There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective use during cardiac arrest.
Action Planned (AI summary) The Department for Education published guidance on automated external defibrillators in April 2016 and has since published new guidance relevant to further education colleges. They will also write to the Association of Colleges to highlight this guidance. The Resuscitation Council UK promotes CPR and AED use through education, research, and collaboration, including overseeing the distribution of £1,000,000 for public access defibrillators and redesigning PAD signage. NHS England acknowledges concerns about out-of-hospital cardiac arrest survival. The Treasury has allocated £2m for public access defibrillators, and the Department for Education has issued guidance encouraging CPR training and PADs in schools. The BHF provides training resources for CPR and PAD familiarisation, funds PADs, and offers a Genetic Information Service for inherited heart conditions, which they have promoted to coroners.
Robert Davidson
All Responded
2016-0363 13 Oct 2016
Aran Court Care Centre Care Quality Commission Department of Health and Social Care +2 more
Care Home Health related deaths
Concerns summary (AI summary) Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Noted (AI summary) Priory Group will raise the need for effective communication at resident transfer in their Safety 1st bulletin and highlight the requirement to complete Form AM32 Transfer/Discharge record. Avery acknowledges shortcomings at Aran Court under previous management and has implemented an additional action plan and timetable to fully embed Avery's policies and procedures. NHS England outlines its commissioning role and refers to the Care Certificate as a new minimum standard for care workers. They state that the commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The CQC details inspections carried out at Aran Court Care Centre and Jubilee Gardens, noting expectations around risk assessments and handover documents when patients transfer between services. The Department of Health acknowledges the importance of workforce skills development and highlights the introduction of the Care Certificate and funding for training.
Karnel Haughton
Historic (No Identified Response)
2016-0339 23 Sep 2016
Department for Education National Society for the Prevention of …
Other related deaths
Concerns summary (AI summary) Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Raymond Woodward
All Responded
2016-wp25391 26 Aug 2016
Medicines and Healthcare Products Regul…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The risk of adverse cardiovascular reactions to Buscopan, especially in patients with ischaemic heart disease, is not widely known, and the Summary of Product Characteristics (SPC) for intravenous Buscopan could be more specific regarding this risk.
Action Taken (AI summary) The Summary of Product Characteristics (SmPC) for Buscopan Ampoules has been updated to more clearly communicate and minimise the risk of serious adverse reactions in patients with underlying cardiac disease. These recommendations have also been communicated to healthcare professionals through an article in the MHRA newsletter, Drug Safety Update.
Winston Harris
All Responded
2016-wp25349 3 Aug 2016
Birmingham City Council Kerria Court residential home Sandwell and West Birmingham Hospitals …
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not consider an emergency DOLS despite his dementia and previous attempts to leave; the DOLS application was not processed before his death.
2 responses from Birmingham City Council, Sandwell and West Birmingham NHS Trust
Patricia Cleghorn
All Responded
2016-0270 25 Jul 2016
Birmingham and Solihull Mental Health T… Care Quality Commission NHS England: Department of Health
Community health care and emergency services related deaths
Concerns summary (AI summary) The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Noted (AI summary) NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to develop local multi-agency suicide prevention plans by 2017, supported by further national investment from 2018/19. The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a matter for local commissioners, addressed by NHS England's response. The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the Medicines Code by the end of November 2016. The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust and their impact of those actions on patients at the quarterly meeting with the Trust in December 2016.
Sydney Neil
All Responded
2016-0256 15 Jul 2016
Birmingham Cross City Clinical Commissi… NHS England Wychall Lane Surgery
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Action Planned (AI summary) Following a SUDIC case discussion, the practice incorporated continuous oxygen saturation readings during nebulisation into their acute asthma management protocol and implemented outcomes from a serious case review into their emergency protocol. NHS England acknowledges the concern regarding suction equipment and oxygen at the GP surgery, and highlights ongoing work to improve asthma management in primary care by communicating updated guidelines to GP practices and CCGs. They have also requested that the CQC ensure primary care services carry the necessary equipment and skills to address respiratory emergencies. The CCG reviewed guidance on basic equipment requirements for GP practices, including CPR training and equipment such as AEDs and oxygen, and will ensure practices adhere to this guidance via contract visits and disseminate learning from this incident to other CCGs.
Terence Stilges
Partially Responded
2016-0293 30 Jun 2016
Heart of England NHS Foundation Trust NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.
Action Taken (AI summary) NHS England supports the Heart of England NHS Foundation Trust's actions to review electronic systems, ensure junior doctors are aware of the discharge process through training, have individual clinicians review the event in their annual appraisal, and include the event in their internal quality improvement process.
Richard Grant
All Responded
2016-0157 21 Apr 2016
Black Country Partnership NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.
Action Taken (AI summary) Black Country NHS has developed and shared a MHLS checklist and reviewed the SPOR duty system. MHLS standard has been developed requiring all letters are drafted within the same or following shift and are dispatched within 3 working days.
Leslie Carswell
Partially Responded
2016-0147 19 Apr 2016
Sandwell and West Birmingham NHS Trust University Hospital Birmingham NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
Action Taken (AI summary) The Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and documentation requirements. All radiographers are being trained in IEP and Image Link and a weekly data report from the CRIS system has been set up to monitor image transfers performed out of hours.
Luke Ayres
All Responded
2016-0148 15 Apr 2016
Birmingham and Solihull Mental Health N…
Mental Health related deaths State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.
Action Planned (AI summary) The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust will also implement a more robust approach to Environmental and ligature risk assessments and extend the simulation of medical emergencies on wards.
Ronald Bentley
Partially Responded
2016-0086 3 Mar 2016
British Cardiac Intervention Society British Society of Interventional Radio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.
Noted (AI summary) The British Cardiovascular Intervention Society (BCIS) circulated the report to its members via its official newsletter and passed on details to the British Heart Rhythm Society (BHRS).
Edna Cleaton
Historic (No Identified Response)
17 Dec 2015
Jockey Road Medical Centre
Community health care and emergency services related deaths
Concerns summary (AI summary) The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
William Driscoll
Historic (No Identified Response)
16 Dec 2015
The Driver and Vehicle Licensing Author…
Road (Highways Safety) related deaths
Concerns summary (AI summary) There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals being permitted to drive.
Joyce Tozer
Historic (No Identified Response)
15 Dec 2015
University Hospitals Birmingham NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.
Kamrul Rubel
Historic (No Identified Response)
15 Dec 2015
Birmingham City Council
Other related deaths
Concerns summary (AI summary) The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.
Ricky Hudson
Historic (No Identified Response)
1 Dec 2015
Department for Transport Driver and Vehicle Licensing Agency Driver and Vehicle Standards Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, posing significant safety risks due to insufficient regulations.
Dean Boland
Partially Responded
2015-0486 25 Nov 2015
Birmingham Community Healthcare NHS Tru… Birmingham Prison National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.
Action Taken (AI summary) Detox unit staff completed training on supervising opiate substitution medication, and awareness training is scheduled for completion in January 2016. Monthly strategy meetings are held to discuss drug misuse, and attendance from prison officers on B Wing is mandatory. Widespread testing for psychoactive substances as part of the MDT process is planned for April 2016.
Michael Logue
All Responded
2015-0426 4 Nov 2015
Central Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary) A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.
Action Planned (AI summary) Following a significant event review, the practice agreed to share the event with clinicians to improve practices, undertake more detailed patient examinations with full documentation, and for Dr. Eedle to contact the hospital to improve post-operative patient care communication.
Allan Beasley
Historic (No Identified Response)
26 Oct 2015
Sunrise care home
Care Home Health related deaths
Concerns summary (AI summary) Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.
Hireiti Kuflesion
Historic (No Identified Response)
2015-0414 23 Oct 2015
Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E +3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.