North Lincolnshire and Grimsby
Coroner Area
Reports: 6
Earliest: Dec 2013
Latest: 12 Dec 2023
Reece Nelson
All Responded
2024-0001
12 Dec 2023
Navigo
Suicide (from 2015)
Concerns summary (AI summary)
Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.
Action Taken
(AI summary)
Navigo has revised its Community Mental Health and Wellbeing Services Operational Policy to improve staff cover arrangements and inform patients of crisis contact details. Voicemail messages on work phones will include contact details for urgent assistance.
Adam Simms
All Responded
2022-0320
17 Oct 2022
North Lincolnshire Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Blocked drainage gullies were missed during inspections, causing significant standing water on the carriageway. The unexplained accumulation of water indicates an ongoing highway safety risk.
Disputed
(AI summary)
North Lincolnshire Council concludes that the event was unforeseeable due to extreme rainfall and that no further action is needed, as subsequent inspections found no standing water.
Terry Latimer
Historic (No Identified Response)
2017-0178
1 Jun 2017
North Lincolnshire Council
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Maurice Cowling
All Responded
2015-0096
13 Mar 2015
North Lincolnshire and Goole Hospitals …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Noted
(AI summary)
The Trust conducted a patient safety review of three cases and concluded that the complications were managed appropriately and existing arrangements are adequate. They state no further specific actions have been identified, but will be kept under review.
Kevin Pearson
Historic (No Identified Response)
2014-0086
3 Mar 2014
John Somerscales Ltd
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.
Lynne Dring
All Responded
2013-0360
30 Dec 2013
North East Lincolnshire Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
Action Planned
(AI summary)
• The illuminated bollards at the roundabout will be replaced with non-illuminated bollards, positioned to offer the best guidance to motorists while avoiding restricting visibility to pedestrians.
• All sites where WBM 294 (elephants footprints) road markings have been installed have been identified.
• A program of removal has been compiled, with the intention of removing markings at 10 sites being the priority, including Hewitt's Circus roundabout.