Greater Lincolnshire

Coroner Area
Reports: 65 Earliest: Aug 2013 Latest: 6 Jan 2026

57% response rate (below 62% average).

65 results
Joshua Booth
All Responded
2015-0125 16 Mar 2015
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns 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.
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 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.
Thomas Hunt
All Responded
2015-0004 9 Jan 2015
North Lincolnshire Council
Road (Highways Safety) related deaths
Concerns summary A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a village road bordered by residential properties is deemed inappropriate and should be reduced.
John Stabler
Historic (No Identified Response)
2014-0552 18 Dec 2014
HMP Lincoln National Offender Management Service HMP North Sea Camp +2 more
State Custody related deaths
Concerns summary The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
Elaine Giles
Historic (No Identified Response)
2014-0529 5 Dec 2014
Peterborough and Stamford NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.
Iris Grimwood
Historic (No Identified Response)
2014-0384 26 Aug 2014
United Lincolnshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Kenneth Paul
Historic (No Identified Response)
2014-0338 23 Jul 2014
Department for Transport
Road (Highways Safety) related deaths
Concerns summary The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative requirement for such safety features on light commercial vehicles, creating an unnecessary risk.
John Thorpe
Historic (No Identified Response)
2014-0340 23 Jul 2014
Lincolnshire East Clinical Commissionin… East Midlands Local Education and Train…
Other related deaths
Concerns summary The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
Sidney Harvey
Historic (No Identified Response)
2014-0075 26 Feb 2014
South Kesteven District Council
Other related deaths
Concerns summary Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or safety upgrade.
Hazel Polkinghorn
Historic (No Identified Response)
2014-0078 26 Feb 2014
Ministry of Justice
Mental Health related deaths
Concerns summary The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.
Sean Cunningham
Historic (No Identified Response)
2014-0087 26 Feb 2014
Martin-Baker
Product related deaths
Concerns summary A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.
Craig White
Historic (No Identified Response)
2014-0017 14 Jan 2014
Lincolnshire Community Health Services … United Lincolnshire Hospitals NHS Trust British National Formulary +4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Susan Jill Hammond
All Responded
2013-0286 4 Nov 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 summary United Lincolnshire Hospitals NHS Trust has revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergies, and updated prescription charts to include prompt
Jessica Ashton-Pyatt
Historic (No Identified Response)
2013-0200 30 Aug 2013
United Lincolnshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Dimitar Shtarbov
Historic (No Identified Response)
2013-0178 8 Aug 2013
South Lincolnshire Clinical Commissioni… East Lincolnshire Clinical Commissionin…
Accident at Work and Health and Safety related deaths
Concerns summary Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.