Northamptonshire

Coroner Area
Reports: 49 Earliest: Sep 2014 Latest: 19 Feb 2026

71% response rate (above 62% average).

Response Status
Responded 35 No Response 2 Historic 9 Pending 3
AI Classification
Action Taken 78%
Action Planned 11%
Noted 11%
Disputed 0%
Based on 9 classified responses
Top Categories
Hospital Death (Clinical Procedure… (20) Road (Highways Safety) related dea… (8) Suicide (from 2015) (7) Alcohol, drug and medication relat… (5) Care Home Health related deaths (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East Midlands average: -19 reports · +7pp response rate
vs national average: -34 reports · +9pp response rate
49 results
Jack Knapman
All Responded
2022-0405 16 Dec 2022
Home Office
Alcohol, drug and medication related deaths
Concerns summary Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human consumption, risking further deaths.
Alfie Stone
All Responded
2022-0013 14 Jan 2022
East Midlands Ambulance Service
Child Death (from 2015) Emergency services related deaths (2019 onwards)
Concerns summary Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
Andrew Cook
All Responded
2021-0258 18 Jun 2021
Medicines and Healthcare products Regul…
Alcohol, drug and medication related deaths Product related deaths
Concerns summary Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, and various synonyms.
Ann Schuetz
Historic (No Identified Response)
2020-0270 24 Nov 2020
Department of Health and Social Care CaMIS PAS
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.
Mohan Acharya
All Responded
2020-0045 27 Feb 2020
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately 500 deaths annually.
Susan Sterland
All Responded
2020-0062 28 Jan 2020
Kettering General Hospital NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying critical diagnosis of an obstruction.
Blaithin Buckley
All Responded
2019-0465 16 Sep 2019
General Council
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
Diana Gudgeon
All Responded
2019-0015 9 Jan 2019
111 Service East Midlands Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.
David Chandler
All Responded
2018-0215 5 Jul 2018
Carlsberg Supply Co Ltd
Accident at Work and Health and Safety related deaths
Concerns summary An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between contractors for safe isolation.
Andrew Crane
Historic (No Identified Response)
2018-0158 22 May 2018
HMP Ryehill
State Custody related deaths
Concerns summary Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
Gladys Rich
Partially Responded
2018-0149 14 May 2018
Avenue House Nursing and Care Home Care Quality Commission Kettering General Hospital +1 more
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
William Callis
Historic (No Identified Response)
2018-0105 12 Apr 2018
St Lukes Primary Care Centre
Care Home Health related deaths
Concerns summary A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.
Darryl Souza
All Responded
2018-0098 9 Apr 2018
Northamptonshire County Council
Road (Highways Safety) related deaths
Concerns summary Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation timeframe.
Andrea McHugh
All Responded
2018-0060 28 Feb 2018
Thomas Cook
Other related deaths
Concerns summary Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for vulnerable individuals.
Pamela Keech
Partially Responded
2017-0327 28 Jul 2017
British Renal Society Health Education England JRCALC +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients with bleeds for specialist review.
Dianne Macrae
All Responded
2017-0193 16 Jun 2017
Department of Health and Social Care Kettering General Hospital Nursing and Midwifery Council +3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns On 23"' June 2016 an Investigation was commenced into the death of Dianne Jane MACRAE. The investigation concluded by way of inquest on 17"^ and IS'" May 2017. The medical cause of death was:- 1a)...
Vadims Aleksejevs
All Responded
2017-0065 3 Mar 2017
Northampton County Council
Alcohol, drug and medication related deaths
Concerns summary There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, and an unclear statutory duty to house them.
Freda Cordy
Historic (No Identified Response)
2016-0190 17 May 2016
Northampton General Hospital Templemore Care Home
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Mrs Withers
Historic (No Identified Response)
2015-0371 12 Oct 2015
Kettering General Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.
X Rokeby
Historic (No Identified Response)
2015-0048 12 Feb 2015
NSL Care Services
Care Home Health related deaths
Concerns summary Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed receiving no such training whatsoever.
Isobel Griffin and Jane Clark
Historic (No Identified Response)
2015-0049 12 Feb 2015
Northamptonshire NHS Partnership Trust …
Suicide (from 2015)
Concerns summary Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm risks.
Leanne Gower
All Responded
2014-0567 19 Nov 2014
Police Safer Roads Team
Road (Highways Safety) related deaths
Concerns summary Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and informed highway maintenance decisions.
Beatrice Gatt
Historic (No Identified Response)
2014-0566 18 Sep 2014
Shire Lodge Nursing Home
Care Home Health related deaths
Concerns summary A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Dominic Philip
All Responded
2025-0617
Royal College of Radiologists University Hospitals of Northamptonshir… Medicines and Healthcare Products Regul… +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.