Black Country
Coroner Area
Reports: 92
Earliest: Oct 2013
Latest: 6 Feb 2026
74% response rate (above 63% average).
Philip Powell
All Responded
2017-0352
30 Nov 2017
Dudley Group NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Action Taken
(AI summary)
The Trust has equipped all District nurse bags with a box of Debrisoft and has held a meeting with the Debrisoft Rep to discuss the issues when raising a prescription through the GP surgery. The Debrisoft Rep is liaising with GP surgeries and local pharmacies in order to cascade educational advice regarding product and FP10.
Sarah Athersmith
Partially Responded
2017-0350
30 Nov 2017
HM Inspector of Railways
Network Rail
Office of Rail and Road (ORR)
+1 more
Child Death (from 2015)
Railway related deaths
Concerns summary (AI summary)
An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.
Noted
(AI summary)
Network Rail confirms that the crossing was closed to members of the public on 26 September 2017 via temporary order granted by Walsall Local Authority and remains closed today. In 2016 enhancements were made including extending the crossing deck, installing low level solar lighting studs, and de-vegetation works. Walsall MBC are undertaking an urgent review of Network Rail's revised closure application and continue to provide assistance and guidance to Network Rail in the closure application process. As Walsall MBC is not the landowner, it has no authority to convert the crossing into a controlled crossing.
Penelope Benton
All Responded
2017-0349
30 Nov 2017
Dudley and Walsall Mental Health NHS Tr…
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
Action Planned
(AI summary)
The Trust will conduct a review of its standards around discharge communications and reiterate the importance to medical staff that incidents and risk factors are included within discharge letters where this is necessary. Consultant teams also undertake audits in relation to the quality of discharge letters and communication with GPs.
Tahnie Martin
Partially Responded
10 Oct 2017
RICS
ROYAL INSTITUE of CHARTERED SURVEYORS (…
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.
1 response
from Tahnie martin
Reginald Dixon
All Responded
2017-0214
18 Sep 2017
West Midlands Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.
Action Taken
(AI summary)
West Midlands Ambulance Service has provided further education and refresher training around head injuries during NHS Pathways updates. The Trusts Director of Clinical Commissioning and Service Development has also written to the Clinical Commissioning Group regarding resourcing provision, including the Preventing Future Death report.
Anne-Marie James
Historic (No Identified Response)
2017-0210
8 Sep 2017
NHS Lothian Scotland
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health aftercare or family guidance on relapse signs.
Melvin James
Historic (No Identified Response)
2017-0210-wp25845
8 Sep 2017
NHS Lothian Scotland
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.
Spencer Hurst
Partially Responded
2017-0275
16 Aug 2017
Parkhill Group of Companies
Walsall Metropolitan Borough
Other related deaths
Concerns summary (AI summary)
The coroner notes that another young male had died in similar circumstances at the same location in 2007, but there were no adequate notices warning of the risks of swimming, nor fencing or measures to mitigate the risks.
Action Planned
(AI summary)
Parkhill Estates plans to erect a sandstone memorial with safety warnings and four signs at entrances to the Mere, with completion expected by Spring 2018. They will also implement a 6-monthly inspection regime of the signage.
Dorothy Webb
All Responded
2017-0273
16 Aug 2017
Walsall Manor Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.
Action Taken
(AI summary)
The Trust has amended the Serious Incident investigation process to complete reports before future inquests. They have also provided additional training to radiologists, provided feedback to colleagues regarding the red flag system, and produced a lessons learned bulletin.
Aston Soulsby
All Responded
2017-0204
22 Jun 2017
Sandwell Local Authority
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.
Action Planned
(AI summary)
Sandwell MBC is considering installing a formalised crossing point on Crankhall Lane and will alter the outdated carriageway markings, with work planned for completion by 31st March 2018.
Lily Townsend
All Responded
2017-0191
15 Jun 2017
Sandwell and West Birmingham Hospitals …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.
Action Taken
(AI summary)
Recording 'do not resuscitate' orders on a specific computer system, with disciplinary action for deviation, became a requirement on August 1st. A safety summit was held, and a presentation was created to track service changes monthly.
Sarah Poole
All Responded
2017-0176
30 May 2017
Royal Wolverhampton NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.
Action Taken
(AI summary)
The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker. An algorithm for how to manage an abnormal ECG has been developed and will be in place for the next Junior Induction in August 2017. A way of summarizing ambulance handover information into 1-2 sheets has been introduced.
Kenneth Evans
All Responded
2017-0175
30 May 2017
Dudley Group of Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.
Action Taken
(AI summary)
Following the incident, it has been made clear to all staff that the Evergreen area is part of the Trust's services and subject to the VTE assessment policy. Awareness and the need for VTE assessments has been discussed with medical teams and will be raised again at the next mandatory Medicine Audit meeting. The Evergreen area is being reconfigured to re-designate the beds as acute.
Reginald Lewis
Historic (No Identified Response)
2017-0149
4 May 2017
NHS Foundation Trust
New Cross Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.
Abigail Baynham
Historic (No Identified Response)
2017-0104
3 Apr 2017
Black Country NHS
New Cross Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which may have triggered a further assessment.
Beryl Farmer
Partially Responded
2016-0420
24 Nov 2016
Care Quality Commission-
Sandwell and West Birmingham Hospital N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.
Action Planned
(AI summary)
The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face training time will reinforce this pathway in the months ahead and use of Vital Pac and the upcoming installation of new electronic patient record will provide decision support and alerts to reinforce standards.
Vinod Kumar
Historic (No Identified Response)
2016-0369
17 Oct 2016
New Cross Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.
Glen Jordan
Partially Responded
2016-0329
7 Sep 2016
Care Quality Commission
Dudley and Walsall Mental Health NHS Tr…
Mental Health related deaths
Concerns summary (AI summary)
Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.
Action Planned
(AI summary)
The Trust will include a statement in its search policy to enhance the definition of "belongings" to include items used to keep or transport belongings (e.g., bags). They have also commenced a process of implementation, including staff education and a clinical audit planned for April 2017 to evaluate effectiveness.
Tommi-Ray Vigrass
Partially Responded
2016-0241
28 Jun 2016
Care Quality Commission
Walsall Healthcare NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting a tertiary unit and an inadequate handover for the premature baby's arrival.
Action Taken
(AI summary)
Walsall Healthcare NHS Trust has implemented a Regional Cot Locator service, and given medical staff access to the Maternal Badgernet System in addition to the Neonatal system. They have also established a Maternity and Neonatal Task Force and are sharing lessons learned with Neonatal staff.
Kinga Cieciorska
Historic (No Identified Response)
2016-0222
13 Jun 2016
Walsall Healthcare NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, with GP medical notes not seen by the Junior Doctor; details of medication including the significance of the drug, Diclofenac, was not considered.
Richard Parkes
Historic (No Identified Response)
2016-0101
26 Feb 2016
Black Country Family Practice
Community health care and emergency services related deaths
Concerns summary (AI summary)
Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient care continuity.
Marie Rollason
All Responded
2016-0100
24 Feb 2016
Royal Wolverhampton, New Cross Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.
Action Taken
(AI summary)
The Royal Wolverhampton NHS Trust confirms that clinical staff in the Emergency Department receive regular training in the identification and treatment of pulmonary embolism. A training session on venous thromboembolism has recently been delivered, and ECG interpretation is included in training sessions.
Ryan Singh Bhogal
Partially Responded
2016-0038
2 Feb 2016
Lockfield Surgery
New Cross Hospital
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical records during admission.
Action Planned
(AI summary)
The Royal Wolverhampton NHS Trust will introduce a Standard Operating Procedure (SOP) by June 30th, 2016, providing guidance to clinicians on gathering relevant patient information, including accessing GP records. Compliance with the SOP will be audited 6 months after implementation.
Frank Mellers
Partially Responded
2015-0464
17 Nov 2015
Care Quality Commission (CQC)
Walsall Manor Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite the DNAR, and guidelines for DNAR communication may need examination.
Action Taken
(AI summary)
Following a Root Cause Analysis, the importance of ward rounds has been reiterated, a DNAR indicator has been developed on ward boards, the DNAR policy has been reviewed, and a DNAR leaflet has been developed for patients and families. Peer audits are being carried out to review the effectiveness of DNAR forms, and the findings of the inquest have been shared with relevant staff.
Ashley Matthews
All Responded
2015-0297
23 Jul 2015
British Transport Police
Railway related deaths
Concerns summary (AI summary)
Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.
Action Taken
(AI summary)
Palisade fencing has been extended to prevent access, and regular inspections and repairs are being conducted. Signs warning of electrocution dangers have been placed on the overbridge.