Greater Lincolnshire

Coroner Area
Reports: 67 Earliest: Aug 2013 Latest: 1 Apr 2026

55% response rate (below 63% average).

Response Status
Responded 37 No Response 2 Historic 28
AI Classification
Action Taken 33%
Action Planned 39%
Noted 26%
Disputed 2%
Based on 46 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Road (Highways Safety) related dea… (14) Other related deaths (8) Alcohol, drug and medication relat… (5) State Custody related deaths (4)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East Midlands average: -2 reports · -8pp response rate
vs national average: -17 reports · -8pp response rate
67 results
Andre Mickley
Historic (No Identified Response)
2015-0231 17 Jun 2015
Medicines and Healthcare products Regul…
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.
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.
Thomas Hunt
Partially Responded
2015-0004 9 Jan 2015
North LCC Highways North Lincolnshire Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Lincolnshire County Council will assess reducing the speed limit on the B1192 at Brothertoft, following the adoption of a revised Speed Limit Policy expected in Autumn 2015. The council is currently reviewing its Speed Limit Policy, and the revised policy is due to be considered by the Council's Highways and Transport Scrutiny Committee on 9 March 2015.
John Stabler
Historic (No Identified Response)
2014-0552 18 Dec 2014
HMP Lincoln HMP North Sea Camp National Offender Management Service +2 more
State Custody related deaths
Concerns summary (AI 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 (AI 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 (AI 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.
John Thorpe
Historic (No Identified Response)
2014-0340 23 Jul 2014
East Midlands Local Education and Train… Lincolnshire East Clinical Commissionin…
Other related deaths
Concerns summary (AI 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.
Kenneth Paul
Historic (No Identified Response)
2014-0338 23 Jul 2014
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Sean Cunningham
Historic (No Identified Response)
2014-0087 26 Feb 2014
Martin-Baker the MOD
Product related deaths
Concerns summary (AI 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.
Hazel Polkinghorn
Historic (No Identified Response)
2014-0078 26 Feb 2014
Ministry of Justice
Mental Health related deaths
Concerns summary (AI 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.
Sidney Harvey
Historic (No Identified Response)
2014-0075 26 Feb 2014
South Kesteven District Council
Other related deaths
Concerns summary (AI 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.
Craig White
Historic (No Identified Response)
2014-0017 14 Jan 2014
British National Formulary British Society of Gastroenterology Intensive Care Society +4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
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.
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 (AI 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
East Lincolnshire Clinical Commissionin… South Lincolnshire Clinical Commissioni…
Accident at Work and Health and Safety related deaths
Concerns summary (AI 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.