Greater Lincolnshire
Coroner Area
Reports: 67
Earliest: Aug 2013
Latest: 1 Apr 2026
55% response rate (below 63% average).
Stuart Knight
All Responded
2015-0385
22 Sep 2015
East Midlands Ambulance Services
Community health care and emergency services related deaths
Concerns summary (AI summary)
Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Action Taken
(AI summary)
EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for high clinical need cases.
Robert Spring
All Responded
2015-0123
23 Mar 2015
Air Liquide
Lincolnshire County Council
NHS Lincolnshire West Clinical Commissi…
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
Action Taken
(AI summary)
United Lincolnshire Hospitals NHS Trust has met with Lincolnshire Fire & Rescue and Air Liquide to agree a process for sharing information, formalized the discharge process, and included a documented risk assessment in their standard operating procedure. The operating procedure also outlines a clear and agreed communication process between all parties.
Joshua Booth
All Responded
2015-0125
16 Mar 2015
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and an advisory speed limit. Dangerous posts at the bank's foot also necessitate an Armco barrier.
Action Taken
(AI summary)
Lincolnshire County Council reports that the section of road identified as having subsidence has now been levelled. Temporary signage advising of the uneven road surface has been left in place to supplement the existing permanent signs.
Thor Dalhaug
All Responded
2015-0063
6 Mar 2015
United Lincolnshire Hospitals NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.
Action Taken
(AI summary)
United Lincolnshire Hospitals NHS Trust has implemented changes to staff induction, supervision, and investigation procedures following the death. A fresh SUI report was undertaken and process changes were underway to improve analysis of adverse clinical incidents.
Susan Jill Hammond
All Responded
2013-0286
4 Nov 2013
United Lincolnshire Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
Action Taken
(AI summary)
United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between A&E and MEAU, and reviewed the nurse's practice involved in the incident, providing further training and competence assessment.