Leicester City and South Leicestershire
Coroner Area
Reports: 75
Earliest: Sep 2013
Latest: 28 Jan 2026
92% response rate (above 62% average).
Christopher Royal
All Responded
2014-0354
30 Jul 2014
Baron’s Park Nursing Home
Care Home Health related deaths
Concerns summary
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.
Dayani Chauhan-Ahmed
All Responded
2014-0287
30 Jun 2014
University Hospitals of Leicester NHS T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Laura Page
All Responded
2014-0254
28 May 2014
Leicester Partnership NHS Trust
Community health care and emergency services related deaths
Concerns 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.
Paul Millis
All Responded
2014-0176
17 Apr 2014
Leicester City Council
Road (Highways Safety) related deaths
Concerns 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.
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
A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Michael Tarratt
All Responded
2014-0115
14 Mar 2014
Leicestershire Partnership NHS Trust
Community health care and emergency services related deaths
Concerns 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.
Walter Gordon Powley
All Responded
2013-0251
4 Oct 2013
Care Quality Commission
Health and Safety Executive
Registered Nursing Home Association
Care Home Health related deaths
Concerns 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 taken summary
The CQC acknowledges its inspector did not assess against relevant regulations for premises safety in this case. They are piloting a new inspection methodology that will focus on safety and …
Michael Joseph Hirrell
All Responded
2013-0247
1 Oct 2013
Energy UK
Ofgem
Npower
Product related deaths
Concerns summary
Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future deaths.
Action taken summary
Ofgem proposes that the Safety Net wording be made more explicit regarding vulnerable domestic consumers with non-domestic supplies, including a commitment for suppliers to maintain an audit trail. Of
Joan Mary Jones
All Responded
2013-0234
20 Sep 2013
Manor Residential and Nursing Care Home
Care Home Health related deaths
Concerns 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 summary
The Manor has issued a memo to all unit leads to ensure families are contacted after health professional visits, communication sheets are completed and shared, and visits are communicated to …
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
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 summary
The Trust conducted extensive reviews of Mrs Vaghadia's death and current nursing practices, re-iterating vital communication principles through an implemented divisional strategy. They performed two
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
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 summary
The Trust has written to all consultants reminding them of their duty to contact specialist teams for patients with complex needs. They also plan to implement new software by April …