Gloucestershire
Coroner Area
Reports: 42
Earliest: Aug 2013
Latest: 19 Mar 2026
79% response rate (above 63% average).
Barbara Ellis
Historic (No Identified Response)
2018-0038
2 Feb 2018
Gloucestershire Clinical Group
Herefordshire Clinical Commission Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.
Susan Smalley
Historic (No Identified Response)
2017-0409
22 Nov 2017
Gloucestershire NHS Trust
South Western Ambulance Service NHS Tru…
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.
Ronald Brewer
All Responded
2017-0306
19 Oct 2017
Barchester Homes
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Action Taken
(AI summary)
A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. The facts of the case will form a case study for staff training.
Shaun Carter
Partially Responded
2017-0245
29 Aug 2017
Health and Safety Executive
Tonic Construction Ltd
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for managing spoil heaps, increasing the risk of accidents.
Action Planned
(AI summary)
The HSE is participating in a construction industry working group to improve safety related to dumper trucks and spoil heaps, and a manufacturers' sub-group is considering potential dumper truck design improvements. Other improvements being considered include features to prevent driving without a seatbelt and audible warnings.
Rose Workman
All Responded
2017-0435
6 Jul 2017
Gloucestershire Care Services NHS Trust
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Action Taken
(AI summary)
The district nursing service employs measures to ensure that patients are effectively monitored of their ongoing conditions, and the electronic clinical patient record "SystmOne" has undergone extensive re-engineering, launched in April-May 2017. Professional Leads attend handovers and support decision making.
Bonamie Armitage
Partially Responded
2017-0170
25 May 2017
Cotswold Hunt
Council of Hunting
the Masters of Foxhounds Association
Child Death (from 2015)
Other related deaths
Concerns summary (AI summary)
There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.
Noted
(AI summary)
The Master of Foxhounds Association acknowledges the coroner's concerns but highlights its limited regulatory powers over hunts and participants. They will keep safety issues under review and note the Cotswold Hunt's approach to supervision of children.
Steven Amos
Historic (No Identified Response)
2017-0117
6 Apr 2017
Gloucestershire Hospitals NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.
Terence White
Partially Responded
2017-0078
16 Mar 2017
DAC Beachcroft Claims Ltd
Grange Care Centre
Care Home Health related deaths
Concerns summary (AI summary)
The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.
Action Taken
(AI summary)
The Grange Care Centre has made changes to ensure more thorough record keeping for resident's care plans, with daily records kept in individual folders and signed off by the nurse responsible for the shift, and checked by management. It has also introduced "Skin Integrity Boards" and refresher training on skin integrity.
Daphne Cherry
All Responded
2017-0080
13 Mar 2017
Care UK
Care Home Health related deaths
Concerns summary (AI summary)
Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Action Taken
(AI summary)
Care UK has taken actions including training the home manager, deputy, and unit leaders in early recognition of deteriorating patients, delivering training to all staff, introducing daily meetings and walkarounds to discuss residents, and CQC has acknowledged the implemented changes.
Shane Hardy
Historic (No Identified Response)
16 Jan 2017
Change Grow Live
2Gether NHS Foundation Trust
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and no identified lead agency for communication.
Anielka Jennings
Historic (No Identified Response)
2016-0236
27 Jun 2016
Gloucestershire Clinical Commissioning …
Gloucestershire County Council
Child Death (from 2015)
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.
Matthew Gunn
Partially Responded
2016-0217
9 Jun 2016
DWF LLP
W M Morrisons PLC
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
Action Planned
(AI summary)
Morrisons will issue a bulletin to stores instructing employees to report observed epileptic events to a first aider. They will update first aid training and policy, and record epileptic events reported via return-to-work procedures with a reminder to review risk assessments.
Gwendoline Clarke
Partially Responded
2016-0218
8 Jun 2016
ADL PLC
Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary)
Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Action Planned
(AI summary)
The organisation plans to re-enforce the safeguarding policy, update job descriptions, include admission process under general screening, audit care plan, re-enforce home's protocols for unwitnessed accidents, plan training and supervision refresher first aid, review the home's management and on-call process.
Samantha Beach
Historic (No Identified Response)
2015-0413
21 Oct 2015
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community midwives, GPs, and the obstetric department, and the obstetric department was not involved when the patient attended the Emergency Department post-natally.
Diana Hughes
All Responded
2015-0195
18 May 2015
Not Listed
Community health care and emergency services related deaths
Action Planned
(AI summary)
The Trust is considering amending the WHO surgical checklist and reviewing its documentation policy to improve recording of special instructions for post-operative care. Progress will be monitored through the Safety Experience and Risk Group.
Daniel Onley
Partially Responded
2013-0208
19 Sep 2013
Camp Village Trust
Care Quality Commission
Gloucestershire Social Services
Care Home Health related deaths
Concerns summary (AI summary)
Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.
Action Taken
(AI summary)
The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and requested regular audits.
Martin Leslie Brown
Partially Responded
2013-0209
29 Aug 2013
British Board of Agreement
Fletcher's Solicitors
Gloucestershire Constabulary
+4 more
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.
Action Planned
(AI summary)
The BBA has revised paragraph 3.1 of Certificate 06/H120, removing the reference to rural roads, and will reissue the certificate with the revised wording by December 2013.