Nottingham and Nottinghamshire
Coroner Area
Reports: 138
Earliest: Oct 2013
Latest: 8 Apr 2026
78% response rate (above 63% average).
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.
Enid Baber
Historic (No Identified Response)
2020-0120
27 Dec 2019
Nottinghamshire County Council
Other related deaths
Concerns summary (AI summary)
Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.
James Frankish
Partially Responded
2019-0468
9 Oct 2019
British Psychological Society
Chief Medical Officer for England
National Autistic Society
+5 more
Care Home Health related deaths
Other related deaths
Concerns summary (AI summary)
Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Action Planned
(AI summary)
The British Psychological Society will emphasize Pica training and management in Clinical Psychology doctoral programmes and actively support the development and dissemination of multi-professional guidelines relating to the management of Pica.
Evelyn Swift
Historic (No Identified Response)
2019-0354
29 Aug 2019
Beechdale Medical Group
Community health care and emergency services related deaths
Concerns summary (AI summary)
The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
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.
Maureen Woods
Historic (No Identified Response)
2019-0497
24 Jul 2019
AACE - The Association of Ambulance Chi…
National Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through triage are hampered by insufficient resources.
Alexander Davidson
Partially Responded
2019-0149
2 May 2019
NHS England
NHS Pathways
N.I.C.E
+1 more
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Action Planned
(AI summary)
NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting a review of the gastrointestinal suite of pathways, with changes planned for Release 19 (deployed May 2020). NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people.
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.
Polly Drew
Historic (No Identified Response)
2019-0073
24 Feb 2019
Central Medical Services
Suicide (from 2015)
Concerns summary (AI summary)
The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.
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.
Tomas Kelly
All Responded
2017-0412
22 Nov 2017
Chief Medical Officer
Committee on Vaccination and Immunisati…
National Clinical Director for Children…
+1 more
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The JCVI is currently reviewing its advice on varicella vaccination and will consider including children with Down’s syndrome in the list of high-risk groups during meetings in 2018.
Rose Ball
Historic (No Identified Response)
2017-0395
14 Nov 2017
GMC Fitness to Practise Team
Community health care and emergency services related deaths
Concerns summary (AI summary)
A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the doctor's fitness to practice and highlighting wider public safety implications of such practices.
Ryan Vout
All Responded
2017-0376
6 Nov 2017
NHS England
Department for Health
Nottingham County Council
+5 more
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Nottinghamshire County Council has developed a more robust process for communicating demographics and essential risk information in relation to s135(1) warrants between AMHPs and the Police, including a typewritten document sent electronically by the AMHP. They are also exploring a dedicated conveyance service for people detained under the Mental Health Act. EMAS acknowledges its responsibility to provide timely ambulance service for patients with mental health needs. EMAS plans to adapt its operating model with an urgent care tier, which will go live across all five counties on 2 April 2018. The Department of Health acknowledges the concerns raised, focusing on discharge planning and transport for patients sectioned under the Mental Health Act. They state that these matters are operational and for local NHS services to determine, referencing the Crisis Care Concordat.
Douglas Hodges
Partially Responded
2017-0290
12 Oct 2017
Managing Director of Cegedim
NHS Digital
Wells Pharmacy
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for patients.
Action Planned
(AI summary)
A letter is being drafted to all General Practices in England highlighting high-risk cases when a phone call to the pharmacist should be made. A pilot scheme for Urgent Care services is due to be implemented across a controlled geographical area within the next month. Well has rolled out Best in Class Prescription Management across its stores, with field operations management team visits to check implementation and provide support. An improved reporting mechanism has been developed to record audit actions, and SOP14 has been updated.
Shahbaz Salim
All Responded
2017-0237
22 Sep 2017
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Highways England plans to implement a drainage scheme starting in February 2018, including silt removal, pipe repairs, and additional drainage installation. They will also make alterations to the vehicle restraint barrier, pending agreement with a third party, aiming for completion by June 2018.
James Allbones
Historic (No Identified Response)
2017-0336
21 Jul 2017
Bassetlaw Clinical Commissioning Group
Care Quality Commission
Doncaster and Bassetlaw Hospital NHS Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.