Derby and Derbyshire
Coroner Area
Reports: 67
Earliest: Nov 2013
Latest: 3 Mar 2026
79% response rate (above 63% average).
Raees Rauf
Historic (No Identified Response)
2019-0503
12 Dec 2019
Bristol University
Suicide (from 2015)
Concerns summary (AI summary)
The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.
Thomas Reid
Historic (No Identified Response)
2019-0229
28 Jun 2019
Derbyshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the need for improvements.
Aditya Puri
Partially Responded
2018-0268
9 Aug 2018
Balfour Beatty Route Manager
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.
Action Planned
(AI summary)
Highways England collected traffic and road surface data, reviewed fatal collision reports, and will conduct a feasibility study in April 2019 to assess options for safety improvements on the A50 between junctions 3 and 4, subject to funding.
Bryan Allsop
Historic (No Identified Response)
2018-0185
18 Jun 2018
Department for Transport
Other related deaths
Concerns summary (AI summary)
Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.
Charles Grainger
Historic (No Identified Response)
2018-0353
12 May 2018
Derbyshire County Council
Milford House Care Home
NHS Southern Derbyshire Clinical Commis…
Care Home Health related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.
Donald Martin
Partially Responded
2018-0166
28 Mar 2018
RCN Legal Services
New Lodge Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.
Action Taken
(AI summary)
The RCN provides a reflective piece from Ms. Banjoko, detailing CPR processes and awareness of mattress deflation importance, and notes she has remediated her practice, completed basic life support training, and the NMC has closed its case with no further concerns.
Bernard Gerrard
Partially Responded
2018-0070
8 Mar 2018
East Midlands Ambulance Service NHS Tru…
NHS Hardwick Clinical Commissioning Gro…
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.
Action Planned
(AI summary)
EMAS is negotiating with its Coordinating Commissioner regarding the contract settlement for 2018/19 and 2019/20, and anticipates recruiting and training additional frontline operational staff and staff within the Emergency Operations Centre. They have already established an Urgent Care Transport Service (UCTS) which went live on Tuesday 3 April.
Kenneth Cottam
All Responded
2017-0360
7 Dec 2017
Coxbench Hall Residential Home
Care Home Health related deaths
Concerns summary (AI summary)
The court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and falls management, or that staff understood the falls policies and procedures.
Noted
(AI summary)
Coxbench Hall Residential Home asserts that they have clear and robust policies and procedures in place in relation to falls risk assessment and management, including a policy checklist for staff, accident report forms, and a Falls Audit form.
Barbara Sturgess
Historic (No Identified Response)
2017-0209
21 Sep 2017
Ashgate House Nursing Home
Chesterfield Royal Hospital
Care Home Health related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.
Barbara Turner
Historic (No Identified Response)
2016-0386
28 Oct 2016
Derby Teaching Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.
Ann Jacobs
Historic (No Identified Response)
2016-0111
19 Mar 2016
Chesterfield Royal Hospital NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.
Richard Turner
Historic (No Identified Response)
2015-0242
26 Jun 2015
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the risk of fatal collisions with pedestrians.
Sheila Johnson
All Responded
2015-0238
19 May 2015
Tameside Hospital NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Noted
(AI summary)
The Department of Health states that officials have made enquiries with the Trust and have been assured that it will respond appropriately. The CQC will follow up any actions identified as a result of the Trust's response and will reinforce the duties of the Trust in relation to its duty of candour. Tameside Hospital has made considerable changes to improve internal investigations and patient discharge processes, including a review of senior nursing and medical staffing and revised procedures for incident investigations. A system for the urgent recall of patients discharged with potentially life-threatening conditions has been addressed by the Patient Flow Manager.
Louise Henry
All Responded
2015-0013
16 Jan 2015
Derbyshire County Council
Derbyshire Healthcare NHS Foundation Tr…
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.
Action Planned
(AI summary)
Derbyshire County Council will rebrand its recovery team as "Fieldwork (Mental Health)" and launch this at the next Social Care Forum. Derbyshire Healthcare NHS Foundation Trust is undergoing a transformation and will use new terminology in place of 'Recovery Team' by November 2015. NHS England recommends practices review their Serious Mental Illness registers to ensure appropriate patients have information shared with Out of Hours providers. The Medical Interoperability Gateway has been introduced in parts of Nottinghamshire and will be rolled out to the rest of the county and also across Derbyshire, allowing access to coded information in the patient's medical record with consent.
William Beckwith
All Responded
2014-0258
9 Jun 2014
Chesterfield Royal Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.
Action Planned
(AI summary)
The hospital is undertaking a multidisciplinary review of its guidance for assessing elderly patients after a fall, with a clear policy expected by the end of August.
David Cox
All Responded
2013-0355
15 Nov 2013
The Peak District National Park Authori…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river below.
Action Planned
(AI summary)
The Authority installed further permanent signage at both ends of the track in December 2013. They are investigating possible funding streams to implement further measures.
Andrew Cairns, Rachael Slack and Auden Slack
Historic (No Identified Response)
2013-0290
1 Nov 2013
Association of Chief Police Officers
Department of Health and Social Care
Derbyshire Constabulary
+2 more
Other related deaths
Concerns summary (AI summary)
Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.