Nottingham and Nottinghamshire
Coroner Area
Reports: 138
Earliest: Oct 2013
Latest: 8 Apr 2026
78% response rate (above 63% average).
Kevin McDonnell
All Responded
2024-0433
7 Aug 2024
HM Prison and Probation Service
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Action Taken
(AI summary)
HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries.
Bethany Langton
Partially Responded
2024-0544
30 Jul 2024
Department for Science Innovation and T…
Department of Health and Social Care
National Suicide Prevention Strategy Ad…
Suicide (from 2015)
Concerns summary (AI summary)
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal of suicide-related online guidance, facilitates self-harm.
Action Taken
(AI summary)
The DHSC leads an emerging methods working group to prevent access to harmful substances and involves multiple agencies. The Online Safety Act requires services to rapidly remove regulated content and the Government has published a suicide prevention strategy.
Theo Bradley
All Responded
2024-0392
22 Jul 2024
Sherwood Forest Hospitals NHS Foundatio…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.
Action Taken
(AI summary)
Sherwood Forest Hospitals NHS Trust has revised the Antepartum Haemorrhage Guideline and implemented LIMS (Learning in Maternity Services) training, focusing on reacting to blood loss and causes of antepartum haemorrhage. The Trust has updated its Antepartum Haemorrhage (APH) guideline, introduced mandatory training, and implemented escalation processes. Wider cultural work has also been undertaken by the Perinatal Quad.
Ruth Eggleton
All Responded
2024-0354
3 Jul 2024
National Institute for Health and Care …
Other related deaths
Concerns summary (AI summary)
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
Noted
(AI summary)
NICE acknowledges the lack of evidence for specific DOAC reversal protocols and states that clinical judgement is required. They reference existing guidance on head injury and andexanet alfa, and commit to monitoring new evidence.
Arlo Lambert
All Responded
2024-0351
2 Jul 2024
Sherwood Forest Hospitals NHS Foundatio…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Action Taken
(AI summary)
The Trust updated its Antepartum Haemorrhage guideline to emphasize the importance of immediate assessment of fetal and maternal condition with any degree of bleeding. They have also developed a phone assessment section within the guideline and are creating a scenario video for training.
Peter Dickens
All Responded
2024-0286
6 May 2024
Cygnet Health Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised patient care.
Action Taken
(AI summary)
A new registered manager was appointed in January 2023. All staff have undertaken refresher training regarding eating and drinking guidelines, and compliance is monitored through regular audits. Choking incidents will be subject to system-based thematic reviews.
Tommy Gillman
All Responded
2024-0185
4 Apr 2024
Sherwood Forest Hospitals NHS Foundatio…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.
Action Taken
(AI summary)
The Trust acknowledges challenges in meeting RCPCH staffing standards due to recruitment difficulties, but has implemented mitigations including a monthly staffing review and a traffic light escalation system. They have designated a specific area within Majors for children needing medical care out of hours, and established a Children and Young People's Working Group.
Meha Carneiro
All Responded
2024-0187
3 Apr 2024
Sherwood Forest Hospitals NHS Foundatio…
Child Death (from 2015)
Concerns summary (AI summary)
Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover documentation compromised care in the Emergency Department.
Action Taken
(AI summary)
The Trust has taken several actions including updating the Paediatric triage document to require nurses to confirm SBAR verbal handover, implementing structured handover training, instructing staff on accurate record keeping, and implementing a new medical model with a designated doctor overseeing children's care. Compliance with handover documentation is to be monitored via monthly audit.
Alexander Lyalushko
All Responded
2024-0449
25 Mar 2024
Nottinghamshire Healthcare NHS Foundati…
Suicide (from 2015)
Concerns summary (AI summary)
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.
Action Planned
(AI summary)
Nottinghamshire Healthcare NHS Trust is undertaking a further review of the case and addendum to the report. They are transitioning to the new Patient Safety Improvement Framework.
Kenneth Baylis
All Responded
2024-0117
4 Mar 2024
Nottinghamshire Healthcare NHS Foundati…
Suicide (from 2015)
Concerns summary (AI summary)
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Action Taken
(AI summary)
Nottinghamshire Healthcare NHS Foundation Trust has taken several actions, including implementing a new Ward Manager Audit Template, providing a Guide to Carers and Confidentiality, using an MDT Template, and developing a PSIRF policy and PSIRP to improve patient safety incident responses. They have also transitioned to the Learning from Patient Safety Events (LFPSE) system.
Daniel Tucker
All Responded
2024-0115
29 Feb 2024
Department of Health and Social Care
NHS England
Nottinghamshire Healthcare NHS Foundati…
+1 more
Suicide (from 2015)
Concerns summary (AI summary)
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Action Planned
(AI summary)
NHS England detailed updates to overdose guidance, implemented in November 2023, to include callers who reach a Category 5 disposition. Additionally, TOXBASE is to be viewed for each overdose/accidental ingestion incident, and the initial clinical review should consider any ongoing suicidal ideation with a specific plan/means. Nottinghamshire Healthcare NHS Foundation Trust stated that care plans and risk assessments are individualised and updated, with monthly audits to ensure compliance. They have also invested in additional self-harm and suicide prevention training and additional training commenced to support staff and suicide awareness. Ofcom acknowledges the concerns and outlines its plans to implement the Online Safety Act, including consulting on draft codes of practice and taking enforcement action against non-compliant services regarding harmful suicide content. The Department of Health and Social Care references actions taken to address harmful online content such as the Online Safety Act and states that the multi-sector and cross-government suicide prevention strategy for England was published in September 2023.
Kane Boyce
All Responded
2024-0034
17 Jan 2024
HM Prison and Probation Service
Sodexo
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Action Planned
(AI summary)
Sodexo states that the MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include ACCT Assessor training and case manager training. When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before. HMPPS issued guidance and a standard template for Early Learning Reviews (ELRs) in 2021, held a workshop with Group Safety Leads (GSLs) in July 2022, and another in April 2024 to offer additional upskilling. They will mandate the early learning review process in PSI 64/2011 and issue a revised standard template and refreshed guidance document.
Tammy Watkins
All Responded
2024-0017
5 Jan 2024
Nottinghamshire Healthcare NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Action Taken
(AI summary)
The Trust recruited an Associate Director of Physical Healthcare to review physical healthcare across inpatient services. They have also reviewed the process for emergency medical calls and a learning event was held.
Carrianne Franks
All Responded
2024-0032
21 Dec 2023
National Institute for Clinical Excelle…
NHS England
UKHSA
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.
Action Planned
(AI summary)
NHS England developed the TB Action Plan for England, 2021-2026 and commissioned a GIRFT review of TB service provision. They also supported professional awareness resources, a TB eLearning resource, and issued a TB service specification. The UKHSA co-developed and co-owns the National TB Action Plan with NHS England. It has developed and delivered a series of webinars on TB available to healthcare professionals, and contributed to the RCN competency framework for TB nurses. NICE will share the report with their guideline surveillance team to check for new evidence on TB contact tracing. They also plan to discuss the report with the UK Health Security Agency.
Wyndham Thomas
All Responded
2023-0547
21 Dec 2023
HM Prison and Probation Services
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Action Taken
(AI summary)
HMPPS has implemented a revised ACCT case management approach across the prison estate to improve support for prisoners at risk of self-harm or suicide. They are also developing a safety training package for staff which will improve understanding of suicide and self-harm prevention.
Jane Bennett
All Responded
2023-0495
24 Nov 2023
Mansfield District Council
Other related deaths
Concerns summary (AI summary)
Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.
Action Taken
(AI summary)
The council has updated its website to provide further guidance on damp, mould and condensation, trialling environmental monitoring devices for placement in tenant’s homes, increased the capacity of the inspection team and contractors, and procured mould kits for tenant usage. It has also updated its triage system with scripted prompts for all reported damp, mould and condensation cases reported by the tenant.
Michael Daft
All Responded
2023-0475
24 Nov 2023
Nottingham University Hospitals NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
Action Planned
(AI summary)
The trust is developing an updated Infoflex system for MDT coordinators, holding regular MDT excellence meetings, and providing monthly updates to Divisional Management Teams. An MDT Oversight Group will be established in February 2024 to review the project status.
Janet Spencer
All Responded
2023-0541
4 Oct 2023
Nottinghamshire County Council
Care Home Health related deaths
Concerns summary (AI summary)
Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to refuse referrals despite insufficient information.
Action Taken
(AI summary)
Nottinghamshire County Council has implemented a new process and referral/assessment form for hospital and community admissions into Assessment Flat accommodation at Gladstone Court to outline a person's care and support needs, any risks, and updated medical information. They also hold weekly meetings for the Discharge to Assessment Team Managers to review practice and share improvements.
Michelle Whitehead
All Responded
2023-0370
4 Oct 2023
Nottinghamshire Health NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside a lack of guidance for Psychogenic Polydipsia.
Action Taken
(AI summary)
Nottinghamshire Healthcare NHS Foundation Trust has taken immediate actions including a teaching session on Psychogenic Polydipsia within the ‘Trustwide 2-day Physical healthcare Training’, sharing learning from Michelle’s inquest, and reviewing cases of polydipsia in secure settings. The Trustwide Nutrition and Hydration Policy is also under review to specifically reference psychogenic polydipsia.
Gerard Murray
All Responded
2023-0391
1 Sep 2023
Nottinghamshire Healthcare NHS Foundati…
Suicide (from 2015)
Concerns summary (AI summary)
Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient safety.
Action Taken
(AI summary)
Following the death of Mr. Murray, the Nottinghamshire Healthcare NHS Foundation Trust has taken several actions including updating the ward round template to document risk assessments, providing additional training to all qualified staff and MDT members at Sherwood Oaks, and procuring Storm Skills Training package for inpatient services.
Andrew Vizard
Historic (No Identified Response)
2023-0273
20 Jul 2023
Nottingham Healthcare Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Mackenzie Cooper
All Responded
2023-0431
13 Jul 2023
Central England Co-operative
Department of Health and Social Care
Other related deaths
Product related deaths
Concerns summary (AI summary)
A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.
Action Planned
(AI summary)
A review has been conducted and certain improvements have been or are shortly to be made to the system operated by Central England Co-operative Limited, and further discussions with The British Heart Foundation will take place in due course in the interests of a wider positive impact. The Government has provided funding of £1m for a grant scheme to buy life-saving defibrillators for community spaces, which launched in September 2023. All Automatic External Defibrillators (AED’s) granted by the fund must be registered on The Circuit – The British Heart Foundation’s national defibrillator database which is synchronised with the Computer Aided Dispatch systems of the 14 Ambulance Trusts in the UK and holds the location and where required access codes for defibrillators.
Christopher Smith
All Responded
2023-0420
7 Jul 2023
Nottinghamshire Healthcare NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
State Custody related deaths
Concerns summary (AI summary)
Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.
Action Taken
(AI summary)
Nottinghamshire Healthcare NHS Foundation Trust has implemented several improvements, including drill-based NEWS2 training, clear escalation pathways, and additional resources to support the rollout of NEWS2 training. They have also improved processes for supporting staff through the inquest process, including additional training and support from the Medico Legal Team.
Gordon Renfrew
All Responded
2023-0230
6 Jul 2023
Nottinghamshire Healthcare NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.
Action Planned
(AI summary)
The Trust will develop joint learning strategies between Stroke, Neurosurgical, and Neuro-Radiology teams, present decompressive surgery cases at quarterly regional stroke meetings, share minutes of speciality meetings, coordinate responses to SJCRs across specialties, and continue discussing complex Mechanical Thrombectomy cases at the Mechanical Thrombectomy steering group.
Jodie McCann
All Responded
2023-0131
20 Apr 2023
Derby and Burton NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.
Action Taken
(AI summary)
The Intensive Care Unit at Queens Hospital Burton introduced a Critical Care Airway Plan, anaesthetic consultants provided airway management training, and an updated Incident Reporting Policy will include presentations and discussions at Trust learning forums; the Trust is also implementing the Patient Safety Incident Response Framework.