Derby and Derbyshire

Coroner Area
Reports: 67 Earliest: Nov 2013 Latest: 3 Mar 2026

79% response rate (above 63% average).

Clear 40 results
Wendy Boddington
All Responded
2026-0121 3 Mar 2026
NHS Derby and Derbyshire Integrated Car…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of specialist services for dependence and no clear regional or national strategies to address this widespread issue.
1 response from NHS Derby and Derbyshire Integrated Care Board
Peter Thompson
All Responded
2026-0018 13 Jan 2026
Bank Close House Residential Care Home
Care Home Health related deaths
Concerns summary (AI summary) Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.
Action Taken (AI summary) Bank Close House has instructed staff to request a blood glucose test from external healthcare professionals if a diabetic resident shows signs of illness and has asked GP surgeries to provide each diabetic resident’s HbA1c level.
Hannah Booth
All Responded
2025-0615
Derbyshire Community Health Services NH… Derbyshire Healthcare NHS Foundation Tr… NHS Derby & Derbyshire Integrated Care … +2 more
Other related deaths Suicide (from 2015)
Concerns summary (AI summary) Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.
Action Planned (AI summary) NHS England has invested £20 million to connect care records across England by March 2026 and is updating its Healthy Child Programme guidance to include requirements for information sharing and record keeping related to maternal and family health. Regional Chief Nurses will cascade this updated guidance to Trusts. Derby and Derbyshire ICB is working to remove barriers to information sharing by establishing system-wide information governance agreements and applying for Section 251 agreements by Q1 26/27. The ICB will also work with partner Trusts to ensure relevant guidance on information sharing and cross-referencing mother and baby notes is provided by Q1 26/27. Derbyshire Healthcare NHS Foundation Trust has audited GPs not using SystmOne and added an 'alert' to patient records for awareness. They have drafted an information leaflet for GPs about different electronic record systems and added an additional page to e-referral documents for contextual information sharing. Sett Valley Medical Centre has implemented screen alerts on mother/child notes where the mother is under perinatal care and ensures these patients are discussed at monthly MDT and child safeguarding meetings. They also completed suicide prevention training and plan to request acknowledgement of referrals from the perinatal team. Derbyshire Community Health Services NHS FT has incorporated guidance into their Perinatal Mental Health SOP for cross-referencing child and parent records when information is relevant to parental mental health, and implemented an auto-consultation function in SystmOne for this purpose. Locality Managers have been briefed, and a one-page document on record keeping has been shared with staff.
Saranveer Sihota
All Responded
2025-0540 23 Oct 2025
Chesterfield Borough Council
Suicide (from 2015)
Concerns summary (AI summary) The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Action Taken (AI summary) Following a death, Chesterfield Borough Council closed the top floor of a car park and installed full-height, heavy-duty gates and fencing to prevent unauthorized access. Suicide prevention measures were also built into the construction of a newer car park.
Maureen Gilbert
All Responded
2025-0456 8 Sep 2025
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secreta…
Other related deaths
Concerns summary (AI summary) Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to life, especially for residents.
Noted (AI summary) Derbyshire County Council is exploring the feasibility of removing an access bridge to reduce flood risk and constructing a Flood Alleviation Scheme on the Spital Brook. They will also continue to work collaboratively with the Environment Agency to encourage residents to sign up for flood warnings and review existing flood plans and evacuation procedures. The Environment Agency expresses condolences and explains that while they have powers to build flood defences, they are not able to eliminate the risk of flooding entirely. They will continue to work with communities and provide a Flood Warning Service and carry out winter maintenance walkovers. Defra acknowledges the concerns and highlights its national responsibility for flood risk management. The Minister will meet with representatives from Derbyshire County Council and the Environment Agency to discuss flood protection in Chesterfield ahead of winter.
Aaron Atkinson
All Responded
2025-0329 30 Jun 2025
DERBYSHIRE JOINT AREA PRESCRIBING COMMI… National Institute for Health and Care … NHS Derby and Derbyshire Integrated Car… +2 more
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Noted (AI summary) NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. However, the publishers of the CKS will make some changes to ensure it is clear where ECG monitoring is required. The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary care clinicians and across relevant networks, and support service links with colleagues.
Jon-Paul Prigent
All Responded
2024-0648 26 Nov 2024
Department for Transport Driving Standards Agency Agricultural Engineers Association +3 more
Road (Highways Safety) related deaths
Concerns summary (AI summary) Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are outdated, posing significant public road safety risks.
Noted (AI summary) The Department for Transport will examine what more could be done to ensure the roadworthiness of tractors, trailers and coupling devices and will investigate how best to raise awareness of the DVSA's published guidance on maintaining roadworthiness and vehicle loading, as well as of the existing voluntary trailer maintenance scheme. The NFU provides information and guidance to its members via its website, Business Guides, the British Farmer and Grower magazine, and electronic newsletters, and regularly highlights the importance of tractor and trailer maintenance when communicating with its members. HSE outlines its role as Britain’s national regulator for workplace health and safety and highlights that the health and safety legislative framework and associated guidance is sufficient and clear in its requirement to use equipment suitable for the task that is maintained in a safe condition. The AEA and BAGMA would support proposals for change from the Department for Transport including extending mandatory roadworthiness testing to vehicles travelling below 25mph and requiring failsafe breakaway systems on all trailers.
Vera Spencer
All Responded
2024-0616 11 Nov 2024
NHS Derby & Derbyshire Integrated Care …
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated by the absence of an out-of-hours falls service.
Action Planned (AI summary) Derby & Derbyshire ICB will explore developing a falls prevention service for all residents, including injurious falls, and implement options to mitigate long lies following a fall, both to be considered in the 2025/26 planning process.
Alison Binyon
All Responded
2024-0615 11 Nov 2024
Leicestershire County Council
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.
Action Planned (AI summary) Leicestershire County Council will launch a new procedure in January 2025 to ensure an internal review takes place following an unexpected death, with the aim of identifying learning points or needed amendments to policies.
Chad Allford
All Responded
2024-0585 25 Oct 2024
College of Policing Derbyshire Constabulary
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of life-threatening choking risks.
Action Planned (AI summary) Derbyshire Constabulary has designed and implemented a lesson plan covering concealment of items in a subject’s mouth and mandated that safety training includes a scenario covering this topic. They have also contacted the College of Policing to inform them of the concerns raised. The College of Policing is revising the Personal Safety Manual to include guidance on informing a subject about the risk to their life when swallowing drugs. In the interim, communication will be sent nationally to advise forces of this recommendation.
Debra Bates
All Responded
2024-0350 28 Jun 2024
Park Surgery
Care Home Health related deaths
Concerns summary (AI summary) A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
Action Planned (AI summary) The surgery plans to discuss the SOP during an education session, undertake quality improvement work on opioid prescribing (including patient reviews), and review the SOP in July 2025.
Yasmin Adams
All Responded
2024-0330 20 Jun 2024
Ministry of Justice
State Custody related deaths
Concerns summary (AI summary) Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.
Noted (AI summary) HMPPS acknowledges concerns about ACCT observations, shower rails, personality disorder training, and cellular confinement, explaining existing policies and planned improvements without committing to specific new actions.
Miriam Stone
All Responded
2024-0277Deceased 20 May 2024
Derbyshire Healthcare NHS Trust
Suicide (from 2015)
Concerns summary (AI summary) Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy to manage or avoid admissions at these times.
Action Taken (AI summary) Derbyshire Healthcare NHS Foundation Trust has amended its 'Acute Inpatient Mental Health Services for Adults of Working Age Policy and Procedure' to state that admissions during staff shift handover periods should be avoided where possible, unless there is an urgent requirement related to immediate patient safety.
Paul Day
All Responded
2024-0274 10 May 2024
Ministry of Justice
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.
Action Planned (AI summary) HM Prison and Probation Service acknowledges concerns about CPR guidance and will review and revise the guidance regarding rigor mortis as a sign of death, following advice from the Resuscitation Council UK.
Matthew Scott
All Responded
2024-0355 7 May 2024
Highways Authority of Derbyshire County…
Road (Highways Safety) related deaths
Concerns summary (AI summary) A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a significant hazard for drivers, leading to loss of vehicle control.
Action Planned (AI summary) Derbyshire County Council will undertake full width road surfacing work to be completed by 31 October 2024 to level deviations in the road surface.
Derek Hand
All Responded
2024-0580 24 Apr 2024
Scottish Dental Clinical Effectiveness …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.
Noted (AI summary) NHS Education for Scotland (NES) states that blood tests to detect a risk of excess bleeding for patients taking clopidogrel were considered during the development of the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs guidance, but based on expert clinical opinion and published advice, there is no suitable test. They will review the guidance in 2027 or earlier if there are significant developments.
Michael Briggs
All Responded
2024-0208 18 Apr 2024
National Institute for Health and Care …
Other related deaths
Concerns summary (AI summary) Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and potential patient harm.
Action Planned (AI summary) NICE has committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year to determine whether any new information supports a further update of existing NICE guidance.
Zachary Taylor-Smith
All Responded
2024-0152 14 Mar 2024
University Hospitals of Derby and Burto…
Child Death (from 2015)
Concerns summary (AI summary) Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews and capacity assessment for inductions.
Action Taken (AI summary) The hospital has implemented several changes, including mandatory training for maternity staff on CTG interpretation, a new fetal monitoring standard, daily safety huddles, and dedicated maternity flow coordinators. They have also updated their internal escalation policy for maternity and neonatal services.
Sobhia Khan
All Responded
2024-0088 16 Feb 2024
Cygnet Health Care Derby City Council Derbyshire Constabulary +2 more
Other related deaths
Concerns summary (AI summary) Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health Act patients, compounded by insufficient police powers to intervene for public safety.
Noted (AI summary) Derby City Council has made changes to manage mentally disordered offenders, including working alongside the Forensic Community Mental Health Team and finalizing a Memorandum of Understanding to employ a Senior Social Work Practitioner. They also introduced regular training for social supervisors and a rolling programme of Unconscious Bias training. Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, which has undertaken shared cultural awareness training with the police and probation. The Trust has adopted Systm1 as its electronic patient record system and conducts ongoing record keeping audits. Derbyshire Constabulary has strengthened the protection offered to vulnerable people via civil orders and Stalking Protection Orders. The force has a comprehensive programme of activity to raise standards and improve record keeping, and all officers and staff now receive training on cultural aspects. Cygnet has reviewed the PFD action plan at Clinical Governance meetings and shared it with relevant teams; all staff complete a report writing and record keeping Skill workbook, and Cygnet audits on triangulation of records are completed 3 monthly. Response is a placeholder document.
Thomas Langley
All Responded
2024-0029 23 Jan 2024
Travel Lodge
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first aid training, posing a risk during emergencies.
Action Taken (AI summary) Travelodge will extend basic first aid training to all reception team members, including night shift staff, to ensure 24/7 coverage. All other hotel team members will continue to receive first aid information and instruction to act as appointed persons.
Gracie Spinks
All Responded
2023-0479 27 Nov 2023
Derbyshire Constabulary Home Office
Other related deaths
Concerns summary (AI summary) Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Action Planned (AI summary) The Home Office is exploring with stakeholders where Government intervention could improve the criminal justice response to stalking and support for victims, including within the Victims and Prisoners Bill; officials will review statutory guidance on coercive and controlling behaviour and work with the NPCC to gather examples of best practice in policing stalking cases. Derbyshire Constabulary has updated training and guidance, reinforced requirements for record keeping, and reviewed policies regarding found weapons, including issuing specific policy relating to found weapons in October 2023.
Kellie Poole
All Responded
2023-0364 4 Oct 2023
Health and Safety Executive
Other related deaths
Concerns summary (AI summary) There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
Noted (AI summary) The HSE acknowledges the concerns regarding cold water immersion activities, stating that existing regulations and guidance from other organisations (RNLI, National Water Safety Forum) provide a suitable basis for businesses to operate safely. They will not be publishing specific guidance at this time but will keep the activity under review and raise awareness among local authority enforcement officers.
Melvyn Blount
All Responded
2023-0345 21 Sep 2023
Lister House Oakwood
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.
Action Taken (AI summary) The practice has implemented several reviews and changes to prescribing practices and supervision, including a new policy and flow chart for drug alerts, improved documentation, a new consultation booking system and training. An educational event was held to discuss recognition and management of psychotic depression.
Jonathan Cole
All Responded
2023-0186 5 Jun 2023
Ministry of Defence Nottinghamshire Healthcare NHS Foundati…
Other related deaths
Concerns summary (AI summary) There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.
Noted (AI summary) The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work.
Richard Hill
All Responded
2023-0102Deceased 24 Mar 2023
Rugby Football Union
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football Union for volunteer-run organizations.
Noted (AI summary) The RFU expresses sympathy and highlights existing RugbySafe resources on responsible drinking and mental wellbeing, including partnerships with Simplyhealth and Looseheadz. They propose no additional specific action at this stage but will keep it under review.