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
Clear 90 results
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.
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.
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.
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.
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.
Stanislawa Kmiecik
All Responded
2019-0258 25 Jul 2019
URBN UK Ltd
Other related deaths
Concerns summary An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety netting, and presented trip hazards due to an uneven surface, risking falls for staff and the public.
Kathleen McGeary
All Responded
2019-0081 26 Feb 2019
Doncaster and Bassetlaw Teaching Hospit…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture of acceptance.
Malcolm Rathmell
All Responded
2019-0059 20 Feb 2019
Nottinghamshire University Hospitals NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.
Simon Barber
All Responded
2019-0036 28 Jan 2019
First Class Care
Community health care and emergency services related deaths
Concerns summary Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.
George Goldby
All Responded
2018-0104 11 Apr 2018
HC-One
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.
Joan Osborne
All Responded
2018-0091 26 Mar 2018
Adbolton Hall Nursing Home
Care Home Health related deaths
Concerns summary Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Molly Mills
All Responded
2018-0051 21 Feb 2018
Nottingham County Council
Road (Highways Safety) related deaths
Concerns summary A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid white line create significant safety risks.
Elaine Bradbrook
All Responded
2018-0044 14 Feb 2018
United Lincolnshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Michael Drewry
All Responded
2017-0386 28 Dec 2017
Nottinghamshire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.
Tomas Kelly
All Responded
2017-0412 22 Nov 2017
Committee on Vaccination and Immunisati… National Clinical Director for Children… Public Health England
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.
Ryan Vout
All Responded
2017-0376 6 Nov 2017
Department for Health Nottingham County Council Nottingham Police +2 more
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.
Shahbaz Salim
All Responded
2017-0237 22 Sep 2017
Highways England
Road (Highways Safety) related deaths
Concerns summary The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap in the vehicle restraint barrier, which allows unimpeded traffic access.
Rasikaben Chauhan
All Responded
2017-0194 14 Jun 2017
Chief Fire and Rescue Officer
Community health care and emergency services related deaths
Concerns summary There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.
Dipa Lad
All Responded
2017-0019 31 Jan 2017
East Midlands Ambulance Service NHS Tru…
Community health care and emergency services related deaths
Concerns summary The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.