Leicester City and South Leicestershire

Coroner Area
Reports: 75 Earliest: Sep 2013 Latest: 28 Jan 2026

95% response rate (above 63% average).

Clear 60 results
Laura Page
All Responded
2014-0254 28 May 2014
Leicester Partnership NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.
Action Taken (AI summary) The Trust has notified teams of the outcome of the investigation, developed a clear process for handling failed visits, and updated the Crisis Resolution Team's Operational Procedure. They have also clarified time targets for action and the threshold for requesting a welfare check, and the Crisis Service Manager is undertaking weekly audit checks on failed visits.
Paul Millis
All Responded
2014-0176 17 Apr 2014
Leicester City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.
Disputed (AI summary) Leicester City Council asserts the highway design at Troon Way complies with relevant standards and underwent multiple safety audits. They will forward the coroner's comments to the Road Safety Auditor for consideration during the final audit.
Lalitaben Patel
All Responded
2014-0175 13 Apr 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Action Planned (AI summary) DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations.
Michael Tarratt
All Responded
2014-0115 14 Mar 2014
Leicestershire Partnership NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Action Taken (AI summary) An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates are sent and are due to be uploaded within 14 days, with prompts and reminders by June 30th. A case note audit is due within 14 days, with follow-ups every 6 months.
Marjorie Evelyne Keogh
All Responded
2013-0325 4 Dec 2013
Mymill Ltd. c/o Scraptoft Court Residen…
Care Home Health related deaths
Concerns summary (AI summary) The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and non-compliant staircase furniture also posed safety issues.
Action Planned (AI summary) My Mil Ltd instructed a Structural Engineer to look into the balustrading at Syston Lodge and make recommendations to ensure they comply, which will be undertaken once the report is received. CQC is reviewing its approach to registration, considering checks to confirm compliance with building regulations for new or altered locations where providers seek to accommodate people. They will share the report with inspectors and managers within the Commission.
Walter Gordon Powley
All Responded
2013-0251 4 Oct 2013
Care Quality Commission Health and Safety Executive, Head of He… Registered Nursing Home Association
Care Home Health related deaths
Concerns summary (AI summary) Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Action Planned (AI summary) The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection methodology checks high-risk areas, though their inspectors do check that radiators are covered but will often only sample a selection of people's rooms. HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the letter with local authority health and safety regulators and arrange for discussion at the next national local authority practitioner forum. The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue to advise members on risk assessments and safe radiator temperatures.
Michael Joseph Hirrell
All Responded
2013-0247 1 Oct 2013
Energy UK Npower Ofgem
Product related deaths
Concerns summary (AI summary) Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to halt disconnection; and Ofgem was not informed of the death until the coroner's office notified them.
Action Planned (AI summary) OFGEM will monitor suppliers' performance regarding non-domestic disconnections and work with the coroner on reviewing the Safety Net provisions, considering how to promote them to non-domestic suppliers. They also provided context about existing protections for domestic consumers facing disconnection. Energy UK revised the Energy UK Safety Net to clarify protections for vulnerable domestic consumers using a shared non-domestic supply, publishing the updated version on their website. Signatories aim to implement required systems and processes by the end of 2014, with ongoing reviews and audits planned. Npower has briefed affected teams on process changes, organized face-to-face training with annual refresher, and introduced a trial period ceasing disconnection of shared commercial and domestic supplies during winter months. These measures are in addition to existing safeguards for vulnerable customers.
Joan Mary Jones
All Responded
2013-0234 20 Sep 2013
Manor Residential and Nursing Care Home
Care Home Health related deaths
Concerns summary (AI summary) Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Action Taken (AI summary) Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged a consultant to arrange a meeting to address outstanding questions.
Labhuden Amarshi Vaghadia
All Responded
2013-0201 5 Sep 2013
Leicestershire Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Action Taken (AI summary) The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile working solution for community staff.
Karen Sutton
All Responded
2013-0223 4 Sep 2013
University Hospitals Leicester NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.
Action Taken (AI summary) The Medical Director reminded consultants of their duty to contact specialist teams for patients with complex needs, and the hospital expects to have software by April 2014 to alert consultants about patients with specific needs.