Rutland and North Leicestershire
Coroner Area
Reports: 17
Earliest: Aug 2013
Latest: 8 Oct 2025
82% response rate (above 62% average).
James Cochrane
All Responded
2025-0454
5 Sep 2025
Leicestershire Partnership NHS Trust
Mental Health related deaths
Suicide (from 2015)
Concerns summary
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.
Action taken summary
The Trust has updated its carer feedback form, developed a new safety and preventative care plan to incorporate carers' views, and implemented welcome and carer information packs. They also plan …
Patricia Bushell
All Responded
2025-0228
16 May 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.
Action taken summary
The Department for Transport clarified its role in setting legal frameworks and providing guidance to local highway authorities through documents like the Traffic Signs Manual and 'Well Managed Highwa
Susan Lakin
All Responded
2025-0188
11 Apr 2025
Department of Health and Social Care
Medicine and Healthcare Products and Re…
Product related deaths
Concerns summary
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.
Action taken summary
The MHRA has communicated with the online vendor regarding safety concerns, shared the report with the Office for Product Safety and Standards, and published a Medical Device Alert on May …
Anne Towlson
All Responded
2025-0116
10 Feb 2025
Department of Health and Social Care
Other related deaths
Concerns summary
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication for a patient undergoing cosmetic surgery abroad.
Action taken summary
The DHSC is considering the impact of medical tourism on patient safety and is engaging with the Turkish Government to improve the patient pathway. They are also considering how to …
Jason Holland
All Responded
2024-0490
12 Jul 2024
National Open College Network as part o…
Independent Training Standards Scheme a…
International Powered Access Federation
+3 more
Accident at Work and Health and Safety related deaths
Concerns summary
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
Action taken summary
IPAF plans to table the subject of MEWP rescue, including platform-to-platform, at its Council meeting on September 10th, 2024. Recommendations include forming an industry working group to develop a p
Christopher Larsen
All Responded
2024-0318
13 Jun 2024
Leicestershire Partnership NHS Trust
Suicide (from 2015)
Concerns summary
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of risk assessment decisions, while a nurse failed to review medical records.
Action taken summary
The Trust has introduced a specific prompt for staff to review patient records before 'Safe and Well' calls, updated its Standard Operating Procedure to explicitly require this, and reminded all …
Nazerine Anderson
All Responded
2024-0080
13 Feb 2024
Department for Work and Pensions
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.
Colleen Fletcher
All Responded
2022-0308
20 Jul 2022
Leicestershire and Rutland Integrated C…
Other related deaths
Concerns summary
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.
Christian Devereux
All Responded
2014-0240
23 May 2014
RAC Motorsports Association
Other related deaths
Concerns summary
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.
Lucy Hannah Rose Bailey
All Responded
2013-0176
6 Aug 2013
South Central Ambulance Service
Community health care and emergency services related deaths
Concerns summary
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Action taken summary
South Central Ambulance Service has reviewed and updated the UK ambulance service clinical practice guidance on managing shoulder dystocia. The updated guidance was issued to Medical Directors of Ambu