Nottingham and Nottinghamshire
Coroner Area
Reports: 138
Earliest: Oct 2013
Latest: 8 Apr 2026
78% response rate (above 63% average).
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.
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.
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.
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.
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.
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 (AI 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.
Action Taken
(AI summary)
The Trust has audited compliance with guidelines regarding opiate prescriptions in the latent phase of labour, updated the intrapartum risk assessment document and launched it with staff education, and launched an obstetric shift handover checklist involving multiple staff and structured handover. The obstetric team will review women requiring input with the midwife co-ordinator and anaesthetist, and the midwife co-ordinator will review other women on the labour suite.
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 (AI 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.
Action Taken
(AI summary)
Kings Mill Hospital undertook a multidisciplinary review of their warfarin process, prescription, and supporting documentation. They implemented several immediate actions, including sending out a Learning Matters communication, updating training for junior doctors and nurses, and initiating pharmacy audits for documentation compliance.
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 (AI 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.
Action Planned
(AI summary)
The CCG is working with Nottinghamshire Healthcare NHS Trust on a transformation programme to meet the NHS Long Term Plan requirements over the next 5 years, with increased access to psychological therapies. Monthly transformation meetings have commenced in June 2020. The CCG is working with Nottinghamshire Healthcare NHS Trust on a transformation programme to meet the NHS Long Term Plan requirements over the next 5 years, with standardised service delivery models to be implemented.
Stanislawa Kmiecik
All Responded
2019-0258
25 Jul 2019
URBN UK Ltd
Other related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Following the incident, URBN UK replaced the broken lock, removed moveable items from beyond the gate, instructed staff not to access the area, installed signage, replaced scaffolding with high railings, infilled voids with steel plates, installed a pulley system, and trained staff in harness use.
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 (AI summary)
The coroner notes a lack of comprehensive assessment, investigation, diagnosis, and treatment for the vulnerable patient before discharge, unclear responsibility for discharge decisions, an inadequate electronic discharge summary, and the patient leaving without prescribed antibiotics, as well as a culture of acceptance of these failings.
Action Taken
(AI summary)
The Trust has implemented a discharge checklist and is working to finalise a standard operating procedure after an audit showed only 86% of discharges had a summary. They also issued an apology for a failing in administering antibiotics prior to discharge. They plan to implement an electronic discharge summary within 3 months.
Malcolm Rathmell
All Responded
2019-0059
20 Feb 2019
Nottinghamshire University Hospitals NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, conduct audits, update the HTT Service Operational procedure, and update the Trust’s Clinical Handover of Care and Discharge Policy. The Department of Health and Social Care expresses sympathy and states that they expect the North East London NHS Foundation Trust to look carefully at the care provided and take actions to improve care. They outline national actions being taken to support people with severe mental illnesses and prevent suicide.
Simon Barber
All Responded
2019-0036
28 Jan 2019
First Class Care
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Nottingham City Council has reviewed its Ramping policy to explicitly consider two ramped points of access where there are significant risks or increased fire risk. A commitment has been made to completing risk assessments for all citizens moving into suitable accommodation.
Richard Hill
All Responded
15 Nov 2018
Network Rail
Railway related deaths
Concerns summary (AI summary)
The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.
1 response
from Richard Hill
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 (AI 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.
Action Taken
(AI summary)
HC One allocated an Operational Project Manager, reviewed care plans, allocated staff to supervise eating and drinking, completed swallowing risk assessments, referred residents to SALT, and increased senior management cover; CQC inspection evidenced significant improvements in the quality and safety of care.
Joan Osborne
All Responded
2018-0091
26 Mar 2018
Adbolton Hall Nursing Home
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, and ensuring nurse-led interventions for diabetic residents.
Molly Mills
All Responded
2018-0051
21 Feb 2018
Nottingham County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Nottinghamshire County Council is considering highway improvement measures, including potentially closing access to Home Farm and revisions to the position of the existing central traffic island. They are also considering a localised reduction in the speed limit, all subject to consultation and detailed design work.
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 (AI 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.
Action Taken
(AI summary)
United Lincolnshire Hospitals NHS Trust acknowledges communication issues and historical problems with their Serious Incident (SI) process. They have made significant improvements to the SI process in the last 12 months including training and have asked the Risk Team to commence a SI investigation to review the care and submit an action plan.
Michael Drewry
All Responded
2017-0386
28 Dec 2017
Nottinghamshire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Trust is shortly to introduce the Modified Modified Continuity Index (MMCI) into its routine reporting systems, and staff have been reminded of the importance of timely input in team meetings and managerial supervision on a monthly basis.