Greater Lincolnshire
Coroner Area
Reports: 67
Earliest: Aug 2013
Latest: 1 Apr 2026
55% response rate (below 63% average).
Benjamin Rowley
No Identified Response
2026-0192
1 Apr 2026
Medicines and Healthcare Products Regul…
Medtronic Limited
University Hospitals of Leicester NHS T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; the coroner recommends reporting these events to the Medicines and Healthcare products Regulatory Agency (MHRA) due to concerns about a potential widespread vulnerability.
Luke Ashcroft
No Identified Response
2026-0159
20 Mar 2026
HMP Lincoln
Ministry of Justice
State Custody related deaths
Concerns summary (AI summary)
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.
Robert Gracey
Partially Responded
2026-0004
6 Jan 2026
East Midlands Ambulance Service NHS Tru…
Lincolnshire Police
NHS England
Police related deaths
Concerns summary (AI summary)
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately categorises ABD cases.
Action Planned
(AI summary)
NHS England's regional colleagues have reached out to Derby and Derbyshire ICB, who advised that East Midlands Ambulance Service will be responding directly to the concerns raised, and that the Trust is reviewing Memorandums of Understanding and revising clinical presentation protocols. The Trust will continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD, work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management, and review its internal clinical guidance.
Ayan Sediqi
All Responded
2026-0014
1 Sep 2025
Lincolnshire County Council
Lincolnshire Police
National Highways Midlands region
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and disparate, leading to a failure to act on these critical safety concerns.
Action Planned
(AI summary)
Lincolnshire County Council plans to improve public awareness of road hazard reporting by increasing visibility at public events, using social media, and developing the FixMyStreet platform. They will measure performance via user numbers and feedback, aiming for annual improvement. Lincolnshire Police will support National Highways in promoting their 24/7 Customer Contact Centre for road-related issues. They will incorporate the contact number into public materials, engagement sessions, and digital communications. National Highways will include contact details in all communications, incorporate their website into fleet vehicle livery, establish a Social Media Response Team, explore wayfinding services, and better inform on-road staff. They will also investigate hard plate signage to guide road users.
Jean Dye
All Responded
2025-0412
21 Jul 2025
HSE
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.
Noted
(AI summary)
NHS England will review and update guidance in HTM 06-01 regarding Emergency Power Off (EPO) controls, including the location of reset buttons, with completion due in the financial year 2026-27. Competency and training for engineers will be included in the HTM update. The CQC acknowledges the concerns regarding guidance on Emergency Power Off (EPO) controls, but states it does not have the power to set guidelines or training expectations. They note that the Trust has confirmed actions taken including durable labels on EPOs, quarterly Electrical Safety Group meetings, and completed installation reports.
David Walsh
All Responded
2025-0319
23 Jun 2025
Lincolnshire County Council
Lincolnshire Police
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.
Action Taken
(AI summary)
Lincolnshire County Council and Lincolnshire Police have agreed that every STATS19 collision form listing road-related factors will be highlighted within the wider LCC Highways Team for early review and action.
Jonathan Szczepanski
All Responded
2024-0271
17 May 2024
Lincolnshire Integrated Care Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.
Action Planned
(AI summary)
The ICB will add a statement to the Lincolnshire Formulary reminding users to prescribe PPIs with NSAIDs, and will highlight NICE guidelines in the Medicines Optimisation newsletter and primary care Bulletin. It will also share a case study at the Medicine Safety Network meeting and the Prescribing Forum.
Frederick Powell
All Responded
2023-0406
24 Oct 2023
Acis Housing
Other related deaths
Concerns summary (AI summary)
Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.
Noted
(AI summary)
Acis Group acknowledges the coroner's concerns, referred the issue to the Regulator of Social Housing and the National Housing Federation, and raised awareness within the social housing sector, asserting no breach of regulatory standards or statutory obligations.
Lilian Board
All Responded
2023-0368
5 Oct 2023
United Lincolnshire Hospitals NHS Trust
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.
Noted
(AI summary)
United Lincolnshire Hospitals NHS Trust expresses condolences and clarifies the policy for supplying patients with 14 days of medication upon discharge. They argue that the current policy appropriately balances patient needs with potential risks, given that the patient had a supply of medication that was likely fatal in overdose.
Sheila Johnson
All Responded
2023-0319
6 Sep 2023
Phoenix Care Centre
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.
Action Planned
(AI summary)
The care home manager will personalise existing generic policies. The care home manager will personalise existing generic policies.
Absolom Duffy
All Responded
2023-0295
16 Aug 2023
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" command would be safer.
Noted
(AI summary)
Lincolnshire Council will assess vegetation at the junction regularly to ensure maximum visibility. However, they are not proposing to change the existing GIVE WAY signage as the visibility at the junction exceeds requirements.
Elizabeth Agbejimi
All Responded
2023-0232
6 Jul 2023
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.
Action Taken
(AI summary)
The Trust is implementing mandatory documentation requirements for ED clinicians acknowledging blood gas results, including noting abnormalities and planned management. They will communicate the potential altered response to infection in those with Trisomy 21 to relevant teams and remind them to fully review ED notes. Clinical audits will be undertaken to assess embedding of the learning.
Colin Gumm
All Responded
2023-0138
26 Apr 2023
Lincolnshire County Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.
Noted
(AI summary)
The council explains existing processes for safeguarding and quality monitoring of care providers, stating they are satisfied that appropriate assurances are undertaken to see whether action does need to be taken by the wider council as a result of an individual’s death.
Vincenzo Lippolis
Partially Responded
2022-0339
26 Oct 2022
LPFT Legal Services
NAViGO Grimsby
Suicide (from 2015)
Concerns summary (AI summary)
Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced by a telephone call, leading to case closure.
Disputed
(AI summary)
NAViGO disputes the coroner's concerns, stating that the decision not to section Mr. Lippolis followed nationally recognized practice and the professional judgement of experienced practitioners, based on his presentation at the time.
Emma Simkin
All Responded
2022-0313
12 Oct 2022
Vine Street Surgery and LPFT Legal Serv…
Railway related deaths
Concerns summary (AI summary)
Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.
Action Planned
(AI summary)
Lincolnshire County Council intends to review its AMHP policies to incorporate references to 'masking' and will discuss the coroner's concerns at the next AMHP Forum.
Lilian Shearing
All Responded
2022-0283
14 Sep 2022
Tanglewood Cloverleaf Care Home
Care Home Health related deaths
Concerns summary (AI summary)
Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.
Action Taken
(AI summary)
Tanglewood Cloverleaf Care Home has enhanced monitoring and auditing processes, introduced a new e-learning platform, focused on nutrition and hydration training, employed a care plan manager, and amended the Nutrition & Hydration policy to include current practice of monitoring and recording all intake.
Michael Rolfe
All Responded
2022-0280
7 Sep 2022
United Lincolnshire Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.
Noted
(AI summary)
The surgery provided a factual account of the patient's consultations and treatment based on medical records, noting the author was not involved in the patient's care and is no longer at the practice.
Dainton Gittos
Historic (No Identified Response)
2022-0269
31 Aug 2022
Constable of Lincolnshire
Child Death (from 2015)
Concerns summary (AI summary)
The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.
Sandra Barnett
All Responded
2024-0019
5 Apr 2022
Holme Farm
Other related deaths
Concerns summary (AI summary)
The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, indicating a potential ongoing risk.
Action Taken
(AI summary)
Following the incident, the property owners added a second handrail to the staircase, fitted permanent stairgates, and added further information to the AirBnb web pages and Visitors Information pack giving advance notice that this is an old property with steps and stairs.
Levi Petitt
All Responded
2021-0231
6 Jul 2021
Lincolnshire Police
Mental Health related deaths
Police related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There is a need for improved training on mental welfare procedures.
Action Taken
(AI summary)
Lincolnshire Police provides officers with access to a 24/7 phone line with a mental health professional, guides on mental health via mobile data terminals, regular briefings, and trained mental health workers in the FCR for immediate advice and triage.
Christopher Taylor
Historic (No Identified Response)
2021-0175
25 May 2021
Driver and Vehicle Licensing Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary)
An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.
Vilmantas Venskutonis
Historic (No Identified Response)
2021-0154
21 Apr 2021
United Lincolnshire Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, needs to be confirmed and any partial implementation justified.
Christopher Murfet
All Responded
2020-0273
6 Nov 2020
United Lincolnshire Hospitals Trust
Suicide (from 2015)
Concerns summary (AI summary)
Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.
Noted
(AI summary)
The Consultant and Clinical Lead for A&E reviewed Mr Murfet's previous attendances at Pilgrim Hospital A&E Department and stated that on both occasions, Mr Murfet was seen and referred to the appropriate psychiatric service from the A&E Department; and subsequently discharged by them.
Carlington Spencer
Historic (No Identified Response)
2020-0167
28 Aug 2020
Morton Hall Immigration Removal Centre
Nottingham Healthcare NHS Foundation Tr…
State Custody related deaths
Concerns summary (AI summary)
Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.
Toby Nieland
All Responded
2020-0164
26 Aug 2020
Lincolnshire County Council
Lincolnshire Partnership NHS Foundation…
South Lincolnshire Clinical Commissioni…
+1 more
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.
Action Planned
(AI summary)
Lincolnshire County Council plans to implement a working protocol for mental health and substance misuse services, take into account best practice when re-commissioning drug and alcohol services, review dual diagnosis provision, and consider partnership commissioning with the CCG. We Are With You charity has jointly agreed to review Dual Diagnosis pathways, embedded information sharing expectations, and reviewed staff structures to introduce specialist Dual Diagnosis roles. They have also enhanced reciprocal training to LPFT and regularly attend interface meetings and provide opportunities for staff from various organisations to spend time within their teams. The Trust plans to update training programmes to focus on dual diagnosis, reinforce the role of carers, review the Care Programme Approach, and engage with commissioners to ensure appropriate funding for patients with dual diagnoses. They also aim to remove barriers to information sharing and promote data gathering and benchmarking.