Nottingham and Nottinghamshire
Coroner Area
Reports: 138
Earliest: Oct 2013
Latest: 8 Apr 2026
78% response rate (above 63% average).
Thomas Jayamaha
All Responded
2023-0116
4 Apr 2023
Nottinghamshire Healthcare NHS Foundati…
Suicide (from 2015)
Concerns summary (AI summary)
Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Action Taken
(AI summary)
The Trust and ICB have developed an action plan for implementing the autism strategy, including flagging, reasonable adjustments, peer support, care planning, and workforce development. A clinician-led triage assessment is being rolled out across teams to identify complex cases, and a new Clinical Governance Team has been established to review serious incident investigations.
Alexander Braund
All Responded
2022-0407Deceased
20 Dec 2022
HMP Nottingham, Forensic Services Notti…
State Custody related deaths
Concerns summary (AI summary)
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance auditing, risking deaths from unrecognized deterioration.
Noted
(AI summary)
TPP explains how the SystmOne electronic patient record system tracks amendments to consultations, stating that users are informed when an amendment has been made, by whom, and when, and that the audit trail is readily accessible. HMPPS has implemented a training program on medical emergency procedures for staff, including the use of emergency codes and cell entry protocols. A joint training event with healthcare staff was also held to improve care for acutely unwell prisoners, and weekly safety intervention meetings were introduced. The Trust has implemented compliance audit plans for NEWS2, is undertaking joint training with the prison service on several topics, and holds daily handover meetings to discuss prisoner clinical issues.
Quinn Parker
All Responded
2022-0287
21 Nov 2022
Nottingham University Hospital NHS Trust
Child Death (from 2015)
Concerns summary (AI summary)
Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental information.
Action Planned
(AI summary)
The clinical team has been reminded to highlight potential placental pathology on request forms. The Director of Midwifery has reminded midwives to examine placentas prior to sending them to pathology. A new proforma has been introduced for BMS to complete at the time of placenta preparation. The Trust will develop a standard procedure to ensure the medical examiner team informs the pathology laboratory of any neonatal death within 48 hours of birth at the earliest opportunity. The Pathology Department will review examination processes after further information is gained regarding placental examination. The Trust will extend the Pathology stop period across the board for all placentas and have discussions with the Coroner's office where a death occurs within 96 hours. This approach is considered more achievable than trying to predict which of the 975 NICU admissions each year will die.
Carl Wright
All Responded
2022-0324
17 Oct 2022
Nottingham University Hospital NHS Trust
Other related deaths
Concerns summary (AI summary)
Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Action Taken
(AI summary)
Nottingham University Hospital has taken immediate actions, including a Consultant from Linden Lodge physically assessing patients transferred there, and developing a specialty referral guidance and a Standard Operating Procedure (SOP) to review all requested tests for patients daily with documentation.
Rebecca Hayward
All Responded
2022-0321
13 Oct 2022
Nottingham City Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and Care Act re-referrals for changing accommodation are resisted.
Action Planned
(AI summary)
Nottingham City Council has developed an overarching action plan, governed by the Senior Leadership Team and Principal Social Workers, to address the concerns raised; the plan will be reviewed monthly.
Keith Nottle
All Responded
2022-0189
Nottinghamshire Healthcare Trust and Tu…
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary (AI summary)
Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear multi-disciplinary team decision-making.
Action Planned
(AI summary)
Turning Point has reviewed and refreshed helpline worker roles, agreed a Standard Operating Procedure (SOP) with Nottinghamshire Healthcare Trust, ensured staff familiarity with the SOP, introduced additional monitoring and audits, and agreed a competency framework. Nottinghamshire Healthcare is undertaking a comprehensive review of its Crisis Resolution and Home Treatment service, which is currently underway and will lead to an improvement plan by 30 November 2022.
Nigel Saunders
All Responded
2022-0300
3 Aug 2022
HMP Lowdham Grange
State Custody related deaths
Concerns summary (AI summary)
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.
Noted
(AI summary)
HMP Lowdham Grange has updated its DIC checklist to include the Oscar Journal. The use of ACCT tick sheets has been discontinued and all records are contained within the ACCT book. This is a response from a coroner to HMP Lowdham Grange, acknowledging the measures taken and suggesting further alignment with Chief Coroner guidance on disclosure.
Kellum Thomas
Historic (No Identified Response)
2022-0244
3 Aug 2022
Birmingham Women and Childrens Hospital…
the NHS Commissioning team
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.
Jade Hart
All Responded
2022-0228
20 Jul 2022
Doncaster and Bassetlaw Teaching Hospit…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.
Action Taken
(AI summary)
The Trust has taken actions including delivering training and reviewing its serious incident investigation process. They have introduced a 'Memory Capture Document' for staff to record events after an incident.
Beryl Simcock
All Responded
2022-0219
19 Jul 2022
Radcliffe Manor House Care Home
Care Home Health related deaths
Concerns summary (AI summary)
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.
Action Planned
(AI summary)
Radcliffe Manor House plans to introduce a digital care planning system and an online total quality system by the end of the year. They have implemented changes to the falls protocol to ensure relatives are informed and are inviting family members to participate in monthly reviews of the resident’s care plan. Swift Management Services conducted a clinical governance review of Radcliffe Manor House and recommended improvements including investment in an electronic care planning system and training for staff and trustees on clinical governance, risk management, and escalation pathways. The trustees have already made significant improvements in falls management and overall clinical governance.
Michelle Whitehead
All Responded
2022-0016
19 Jan 2022
Nottinghamshire Healthcare NHS Foundati…
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The report identifies concerns relating to sedation medication (unclear dose/type, possible excess, poor documentation), delayed recognition of patient's declining condition, lack of medical clerking and consultant involvement, delays in contacting the duty doctor and paramedics, and delays in paramedics accessing the ward; the coroner notes these issues have been raised in previous inquests.
Action Planned
(AI summary)
Following a medication error, staff received supervision and completed self-reflection. The Trust is conducting an audit, creating a Quality Improvement Plan, and plans to share learnings with the family and the coroner by the end of May 2022.
Terance Radford
All Responded
2022-0014
18 Jan 2022
Minister of State for Prisons and Proba…
Other related deaths
Concerns summary (AI summary)
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk management.
Action Planned
(AI summary)
The Ministry of Justice will issue an instruction to prison governors that no prisoner held in a segregation unit should be released on HDC and will prioritise necessary amendments to the Framework so that changes not being made immediately will be in place by the summer. An investigation has been instigated under Prison Disciplinary powers into the circumstances of the release including the decision made at HMP Ranby to withdraw the referral made to the independent adjudicator.
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
All Responded
2021-0432
23 Dec 2021
Nottingham University Hospitals NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Action Planned
(AI summary)
The hospital has taken or planned actions to improve ERCP patient pathways, vetting, consent, and accountability, including a specialist HPB endoscopy team and a meeting to design pathways for complex HPB cases scheduled for March 9, 2022.
Rebecca Begg
Partially Responded
2021-0416
8 Dec 2021
Care Quality Commission
Heathcotes Group
Care Home Health related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Action Taken
(AI summary)
Full incident reviews are implemented and the Clinical team now has involvement to understand the root cause and offer different support methods. The internal governance and quality assurance procedures have been reviewed and physical items used to tie ligatures are now stored with the incident report to be sure what was used and how it was removed.
Murray Hyslop
Historic (No Identified Response)
2021-0339
14 Oct 2021
My Care Ltd
My The Orchards Ltd
Nottinghamshire County Council
+2 more
Care Home Health related deaths
Concerns summary (AI summary)
The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.
Paul Barton
Partially Responded
2021-0338
14 Oct 2021
Aviva Insurance
Nottinghamshire Healthcare NHS Foundati…
Nottinghamshire Police
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation was inaccurate and inadequate.
Action Planned
(AI summary)
The Trust plans to review CRHTT processes, update policies, and invest in centralised investigators and a family liaison service to improve serious incident governance and support for families.
Morris Reddington
Partially Responded
2021-0312
East Midlands Ambulance Service NHS Tru…
Nottingham University Hospitals NHS Tru…
Sherwood Forest Hospitals NHS Foundatio…
+2 more
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be missed and delaying correct patient pathways.
Action Planned
(AI summary)
NHS England is developing a thrombectomy credentialing programme with medical bodies to address workforce gaps, piloting a new data set for service expansion, and creating an ISDN-level implementation strategy for widespread 24/7 mechanical thrombectomy rollout. Nottingham University Hospitals NHS Trust has established the CareCentric Portal as its main conduit for ePRFs from EMAS. The trusts are implementing automated processes for ePRF sharing via CareCentric to improve accessibility for handover and wider benefits.
Jacob Owczarek
Partially Responded
2021-0259
28 Jul 2021
Care Quality Commission
Doncaster and Bassetlaw Teaching Hospit…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor recording of radiology discussions.
Action Planned
(AI summary)
The Trust is updating its Sepsis Action Plan and has created a detailed action plan in response to the coroner's report, which will be monitored by the Children & Families and Medical Division with the oversight of the Quality and Effectiveness Committee.
Heather Page
All Responded
2021-0213
23 Jun 2021
Broxtowe Borough Council
Derbyshire County Council
Erewash Borough Council
+1 more
Community health care and emergency services related deaths
Railway related deaths
Concerns summary (AI summary)
Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.
Noted
(AI summary)
Nottinghamshire County Council asserts its duty to protect public highway rights regarding level crossings, clarifies the roles of Network Rail and the public in crossing closures, and states it has been supportive of safety improvements. Network Rail acknowledged past unsuccessful attempts to change level crossings in the area and expressed willingness to work with local authorities to find potential solutions. Derbyshire County Council provides an explanation of their previous involvement in a 2003 proposal to divert Public Footpath No.7, and clarifies that they will work with other agencies to improve safety across the County. Broxtowe Borough Council has scheduled a meeting with Network Rail to seek potential solutions to concerns raised, and will provide further information after the meeting. Erewash Borough Council stated that they previously supported Network Rail's Level Crossing Closures Programme, and would still not oppose the closure of the Barton Road crossing if Network Rail recommends it, though they prefer an accessible footbridge.
Steven Oscroft
All Responded
2021-0162
12 May 2021
Driver and Vehicle Licensing Agency
Paul Wainwright Construction Services L…
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk of materials falling from vehicles.
Action Planned
(AI summary)
DVSA will work with HSE to amend load security guidance on GOV.UK to include specific narrative on bulk loads, aiming to have it ready by September 2021. They will arrange special road checks focused on bulk trailer skip lorries, starting in September, and produce dedicated communications highlighting the revised guidance. The company has upgraded its sheeting and restraint systems for all vehicles to increase load cover and security, and is having its Health and Safety Consultants design ongoing training criteria and schedules for drivers.
Owen Hinds
All Responded
2021-0391
7 May 2021
Nottingham and Nottinghamshire Clinical…
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to fall between existing care criteria.
Action Planned
(AI summary)
The CCG plans to develop an all-age pathway for ARFID patients, including those with ASD, through a working group, patient engagement, and service transformation. They outline a timeline of activities including needs assessment, literature review, pathway development, and workforce training.
Sean Fegan
Partially Responded
2021-0083
25 Mar 2021
GP
GP, Change Grow Live, Nottinghamshire H…
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading to misinterpretation of needs.
Action Planned
(AI summary)
The Trust will deliver mandatory training in learning disability and autism for all health and social care staff, piloted from April 2021. Learning from Autism Deaths Thematic Review will be included in training and future service developments, monitored through a Quality Improvement Plan.
Philippa Day
All Responded
2021-0043
12 Feb 2021
Capita
Department for Work and Pensions
Alcohol, drug and medication related deaths
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.
Action Planned
(AI summary)
The DWP has already introduced a highly visible "watermark" in the PIP computer system showing if a customer has additional support needs. Script changes to better support vulnerable claimants will go live by the end of May 2021, and strengthened wording regarding DLA will be introduced by early May 2021. Capita is pausing the issue of appointment letters during Change of Assessment or Further Review periods. They are also working with DWP to review the tone and language in written communications. Full implementation of the changes will be in place by 30 September 2021.
Norma Lockton
Historic (No Identified Response)
2021-0017
16 Jan 2021
Care Quality Commission
Jubilee Court Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical assistance and an inadequate post-death review.
Noah Poole
All Responded
2020-0206
9 Oct 2020
Royal College of Nursing and Midwifery
Royal College of Obstetrics and Gynaeco…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.
Action Planned
(AI summary)
The RCOG commits to developing a Scientific Impact Paper on the management of IFH to inform practice and scaling training nationally to improve outcomes.