Rutland and North Leicestershire
Coroner Area
Reports: 17
Earliest: Aug 2013
Latest: 8 Oct 2025
82% response rate (above 63% average).
James Cochrane
All Responded
2025-0454
5 Sep 2025
Leicestershire Partnership NHS Trust
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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
(AI summary)
The Trust has implemented several changes, including ensuring carers' views can be documented with consent, incorporating carer perspectives into safety plans, and updating risk assessment documentation to include carer input. They also provide support to carers via signposting and offer a Carers pack, and are launching a course for carers through the Leicestershire Recovery College.
Patricia Bushell
All Responded
2025-0228
16 May 2025
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI 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 Planned
(AI summary)
While noting existing guidance, the Department for Transport will ensure the issue of temporary signage during maintenance works is considered as part of their current update to the Code of Practice.
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 (AI 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.
Noted
(AI summary)
MHRA acknowledges the concerns about support belts lacking warnings and guidance, provides background on its regulatory role, and explains existing device regulations and post-market surveillance activities, including Yellow Card scheme and collaborations. It highlights manufacturer responsibilities for safety and labeling. The response includes details on the product and its instructions for use. The DHSC acknowledges the concerns regarding the lack of warnings and information on lap belt products, states that the responsibility for these concerns sits within another organisation, and will be writing to the Office of Product Safety and Standards. OPSS has written to major online marketplaces (Amazon, eBay, Temu, Shein and Alibaba) to make them aware that certain products may not be provided with suitable instructions or warnings to assure safe use by likely users, and alerted online marketplaces to its Product Safety Report published for the ORTONES belt to make clear this product should not be supplied.
Anne Towlson
All Responded
2025-0116
10 Feb 2025
Department of Health and Social Care
Other related deaths
Concerns summary (AI 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 Planned
(AI summary)
The DHSC is considering the impact of medical tourism on patient safety and engaging with the Turkish Government to improve the patient pathway. The UK Government is also considering how to communicate risks to those considering medical treatment abroad.
Jason Holland
All Responded CC
2024-0490
12 Jul 2024
Independent Training Standards Scheme a…
LANTRA
National Open College Network as part o…
+3 more
Accident at Work and Health and Safety related deaths
Concerns summary (AI 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.
Noted
(AI summary)
IPAF proposes to bring the matter of rescue plans to the industry through its elected members at its board and council meeting to consider its current position on rescue plans and will hold the next IPAF Council meeting on 10th September 2024. RTITB confirms that their MEWP Basic Training course includes sessions on Emergency Escape and Rescue Plans, referencing excerpts from their trainer's guide. NPORS will convene a subcommittee to review rescue plan guidance by October 1, 2024, and will consult with industry bodies to explore improvements, but a timescale will be determined by the responses. AITT states that basket-to-basket rescue is a last resort and provides details of training in how to perform emergency lowering. Lantra will work with NPORS to determine if a specific MEWP Rescue Training Course has a place in the market by October 1, 2024 and will update training materials to highlight the use of a Personnel Platform as a method for rescue by November 1, 2024. IPAF provides guidance for planning and undertaking MEWP recovery and rescue, including platform-to-platform methods, and offers a certified training program. ITSSAR will update its course syllabus to include planning and organisation of work at height, specifically the hierarchy of control measures, and the importance of a company-specific rescue plan and safe systems of work for lone working.
Christopher Larsen
All Responded
2024-0318
13 Jun 2024
Leicestershire Partnership NHS Trust
Suicide (from 2015)
Concerns summary (AI 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 Planned
(AI summary)
The Trust has implemented mandatory training for call handlers, emphasizing the importance of reading patient records and referral documents and prioritising triage calls based on risk. They are also reviewing the layout of the 'safe and well' template to improve information review and risk assessment. The Trust is undertaking a rapid improvement programme using quality improvement methodology to improve serious incident reporting and is holding quality summits focusing on safety, leadership, and governance within the crisis pathway.
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 (AI 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.
Action Planned
(AI summary)
DWP will deliver training sessions to 170 Performance Management team members by the end of June 2024, focusing on identifying and supporting vulnerable customers, including prioritizing the use of the additional support tab in UC system. Upskilling sessions for colleagues who worked on the case are planned. Appointeeship process is also being reviewed with upskilling and system upgrades already concluded.
Colleen Fletcher
All Responded
2022-0308
20 Jul 2022
Executive NHS Leicester
Leicestershire and Rutland Integrated C…
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The ICB has established a task and finish group to review the clinical pathway for management of Hyperglycaemia in Care Homes. The ICB plans to trial new rapid acting insulin guidance, review the existing insulin authorisation form, and support the development of a business case to expand the use of continuous glucose monitors devices for patients in care homes.
Janet Jasper
All Responded
2020-0014
17 Jan 2020
Cadent Gas Ltd
Gas Safe Network
Institution of Gas Engineers
+2 more
Product related deaths
Concerns summary (AI summary)
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.
Action Planned
(AI summary)
Following a review, Gas Distribution Networks (GDNs) have agreed on a revised EM72 policy for responding to gas leak callouts, particularly "no trace" declarations. HSE also undertook communication with residents and gas engineers in the local area, including hosting a residents meeting and providing leaflets to explain potential risks and actions. Gas Distribution Networks (GDNs) clarified procedures for checking adjoining properties during internal gas escape investigations, focusing on external sources. The GDNs will brief operational teams on the revised requirements, expected to be in place across all networks by mid-summer 2020.
Christian Devereux
All Responded
2014-0240
23 May 2014
RAC Motorsports Association
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Motor Sports Association details its history of considering frontal head restraints and insurance policies, and provides statistics on affiliated clubs, license holders, officials and authorised events.
Lucy Hannah Rose Bailey
All Responded
2013-0176
6 Aug 2013
JRCALC
East Midlands Ambulance Service
South Central Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Action Taken
(AI summary)
The South Central Ambulance Service has updated its clinical practice guidance on the management of shoulder dystocia, incorporating advice from specialists in obstetrics and midwifery, and issued it to Medical Directors of Ambulance Trusts across the UK.