Northamptonshire
Coroner Area
Reports: 49
Earliest: Sep 2014
Latest: 19 Feb 2026
71% response rate (above 62% average).
Miss C
Historic (No Identified Response)
2023-0309
25 Aug 2023
Northampton General Hospital Trust
Resuscitation Council UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
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.
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.
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.
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.
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.