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
Frederick White
Partially Responded
2015-0212 3 Jun 2015
Dudley Group NHS Foundation Trust Care Quality Commission West Midlands Ambulance Service NHS Tru…
Community health care and emergency services related deaths
Concerns summary There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.
Eliza Bowen
Historic (No Identified Response)
2015-0160 22 Apr 2015
Springfield House Care Home Bilbrook Medical Centre National Institute for Health and Care …
Care Home Health related deaths
Concerns summary A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes despite a previous raised reading.
Anne Fowler
Historic (No Identified Response)
2015-0104 19 Mar 2015
Home Office
Other related deaths
Concerns summary Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.
Stanley Ward
Historic (No Identified Response)
2015-0045 5 Feb 2015
Care Quality Commission Lapal House and Lodge Care Home
Care Home Health related deaths
Concerns summary Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in anti-coagulant patients and for escalating concerns.
Tracey Bannister
All Responded
2014-0506 21 Nov 2014
Walsall Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.
Lorraine Sheridan
Historic (No Identified Response)
2014-0496 12 Nov 2014
Sandwell Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns summary Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.
Beryl Walters
Historic (No Identified Response)
2014-0489 11 Nov 2014
College of Emergency Medicine National Institute for Clinical Excelle…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
Kirsty Pritchard
All Responded
2014-0565 17 Oct 2014
Black Country NHS Partnership Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.
Nadine Thurman
Historic (No Identified Response)
2014-0303 31 Jul 2014
Dudley and Walsall NHS Mental Health Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.
Bridget Cahill
All Responded
2014-0266 11 Jun 2014
National Institute for Health and Clini…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.
Arnold Soulsby
All Responded
2014-0241 28 May 2014
Department for Transport
Road (Highways Safety) related deaths
Concerns summary Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.
Sukbir Singh Rana & Mandip Singh
Historic (No Identified Response)
2014-0191 30 Apr 2014
Sandwell Metropolitan Borough Council
Road (Highways Safety) related deaths
Concerns summary The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical safe speed for the bend is also 60 MPH.
John Dodd
All Responded
2014-0145 2 Apr 2014
Dudley Group NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Bertram Hamilton
Historic (No Identified Response)
2014-0080 26 Feb 2014
Nursing and Midwifery Council
Other related deaths
Concerns summary A nurse administered insulin to a patient with dangerously low blood sugar, demonstrating a critical lack of understanding regarding insulin administration protocols.
Jason Nock
All Responded
2014-0013 13 Jan 2014
Home Office
Alcohol, drug and medication related deaths
Concerns summary An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Action taken summary The Home Office has requested advice from the Advisory Council on the Misuse of Drugs and is actively collecting evidence on AH-7921. They are also leading an expert panel review …
Lucy Kilvert
Historic (No Identified Response)
2013-0266 21 Oct 2013
National Institution for Health and Cli…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
John James Jackson
Historic (No Identified Response)
2013-0260 16 Oct 2013
Department of Health and Social Care
Product related deaths
Concerns summary An energy mint product contained dangerously high caffeine levels without adequate warnings or information on its packaging or online, posing a risk when consumed like sweets.