Black Country

Coroner Area
Reports: 92 Earliest: Oct 2013 Latest: 6 Feb 2026

67% response rate (above 62% average).

Response Status
Responded 62 No Response 1 Historic 24 Pending 1
AI Classification
Action Taken 56%
Action Planned 22%
Noted 0%
Disputed 22%
Based on 9 classified responses
Top Categories
Hospital Death (Clinical Procedure… (45) Community health care and emergenc… (12) Other related deaths (11) Care Home Health related deaths (9) Road (Highways Safety) related dea… (8)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: +17 reports · +4pp response rate
vs national average: +9 reports · +5pp response rate
92 results
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 The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
Sarah Athersmith
Partially Responded
2017-0350 30 Nov 2017
HM Inspector of Railways Network Rail Walsall Local Authority
Child Death (from 2015) Railway related deaths
Concerns summary An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.
Philip Powell
All Responded
2017-0352 30 Nov 2017
Dudley Group NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Tahnie Martin
Unknown
10 Oct 2017
Accident at Work and Health and Safety related deaths
Concerns summary Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.
Reginald Dixon
All Responded
2017-0214 18 Sep 2017
West Midlands Ambulance Service
Community health care and emergency services related deaths
Concerns 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.
Melvin James
Historic (No Identified Response)
2017-0210 8 Sep 2017
NHS Lothian Scotland
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Anne-Marie James
Historic (No Identified Response)
2017-0210-wp25846 8 Sep 2017
NHS Lothian Scotland
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Dorothy Webb
All Responded
2017-0273 16 Aug 2017
Walsall Manor Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Spencer Hurst
Partially Responded
2017-0275 16 Aug 2017
Parkhill Group of Companies Walsall Metropolitan Borough
Other related deaths
Concerns summary A second death in similar circumstances at the same location highlights a critical failure to implement adequate warning notices, fencing, or other safety measures to mitigate swimming risks.
Aston Soulsby
All Responded
2017-0204 22 Jun 2017
Sandwell Local Authority
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.
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 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.
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 Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.
Sarah Poole
All Responded
2017-0176 30 May 2017
Royal Wolverhampton NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Reginald Lewis
Historic (No Identified Response)
2017-0149 4 May 2017
New Cross Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a further assessment of her mental state and self-harm risk was missed.
Beryl Farmer
All Responded
2016-0420 24 Nov 2016
Sandwell and West Birmingham Hospital N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
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 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 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.
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 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.
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 Missed opportunities to investigate abnormal ECG and tachycardia led to delayed diagnosis. Systemic failures in information recording and transmission, coupled with unconsidered medication contraindications, contributed to inadequate care.
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 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
Partially Responded
2016-0100 24 Feb 2016
New Cross Hospital Royal Wolverhampton
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding Marie Rollason's care.
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 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.
Frank Mellers
All Responded
2015-0464 17 Nov 2015
Walsall Manor Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies for DNAR issuance and communication require urgent review.
Ashley Matthews
All Responded
2015-0297 23 Jul 2015
British Transport Police
Railway related deaths
Concerns 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.