Nottingham City and Nottinghamshire

Coroner Area
Reports: 137 Earliest: Oct 2013 Latest: 15 Jan 2026

77% response rate (above 62% average).

Response Status
Responded 105 No Response 2 Historic 27
AI Classification
Action Taken 69%
Action Planned 16%
Noted 12%
Disputed 4%
Based on 51 classified responses
Top Categories
Hospital Death (Clinical Procedure… (60) Suicide (from 2015) (17) Care Home Health related deaths (15) Community health care and emergenc… (15) Other related deaths (14)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East Midlands average: +69 reports · +13pp response rate
vs national average: +54 reports · +15pp response rate
137 results
Alexander Braund
All Responded
2022-0407Deceased 20 Dec 2022
Forensic Services Nottinghamshire Healt… HMP Nottingham
State Custody related deaths
Concerns 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.
Quinn Parker
All Responded
2022-0287 21 Nov 2022
Nottingham University Hospital NHS Trust
Child Death (from 2015)
Concerns 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.
Carl Wright
All Responded
2022-0324 17 Oct 2022
Nottingham University Hospital NHS Trust
Other related deaths
Concerns summary Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Rebecca Hayward
All Responded
2022-0321 13 Oct 2022
Nottingham City Council
Alcohol, drug and medication related deaths
Concerns 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.
Kellum Thomas
Historic (No Identified Response)
2022-0244 3 Aug 2022
Birmingham Women and Childrens Hospital…
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns 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.
Nigel Saunders
All Responded
2022-0300 3 Aug 2022
HMP Lowdham Grange
State Custody related deaths
Concerns 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.
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 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.
Beryl Simcock
All Responded
2022-0219 19 Jul 2022
Radcliffe Manor House Care Home
Care Home Health related deaths
Concerns 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.
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 Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic failures.
Terance Radford
All Responded
2022-0014 18 Jan 2022
Minister of State for Prisons and Proba…
Other related deaths
Concerns 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.
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 There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
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 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.
Paul Barton
All Responded
2021-0338 14 Oct 2021
Nottinghamshire Healthcare NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns 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.
Murray Hyslop
Historic (No Identified Response)
2021-0339 14 Oct 2021
My Care Ltd My The Orchards Ltd
Care Home Health related deaths
Concerns 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.
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 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.
Heather Page
All Responded
2021-0213 23 Jun 2021
Broxtowe Borough Council Nottinghamshire County Council Derbyshire County Council +1 more
Community health care and emergency services related deaths Railway related deaths
Concerns 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.
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 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.
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 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.
Sean Fegan
Partially Responded
2021-0083 25 Mar 2021
Change Grow Live GP Nottinghamshire Healthcare NHS Foundati…
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 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.
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 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.
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 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.
Wynter Andrews
All Responded
2020-0202 9 Oct 2020
Nottingham University Hospitals NHS Tru…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.
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 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.
Marian Day
All Responded
2020-0199 25 Sep 2020
Sherwood Forest Hospitals NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan for staff.
Patricia Ferguson
All Responded
2020-0155 23 Apr 2020
Bassetlaw Clinical Commissioning Group Mansfield and Ashfield Clinical Commiss… Newark and Sherwood Clinical Commission… +4 more
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.