Nottingham and Nottinghamshire

Coroner Area
Reports: 138 Earliest: Oct 2013 Latest: 8 Apr 2026

78% response rate (above 63% average).

Response Status
Responded 108 Historic 29 Pending 1
AI Classification
Action Taken 54%
Action Planned 36%
Noted 11%
Disputed 0%
Based on 171 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 · +15pp response rate
vs national average: +54 reports · +15pp response rate
Clear 90 results
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.
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.
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.
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 (AI 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.
Action Taken (AI summary) EMAS reviewed its procedures and provided guidance for clinicians dealing with cardiac arrest patients, including additional guidance around futility aligned with BMA, RCUK, and RCN guidance. All clinical staff receive annual refresher training including resuscitation assessments, and dynamic risk assessments are performed for CPR technique.
Shelia Stokes
All Responded
2016-0439 9 Dec 2016
Sherwood Forest Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by an incomplete internal investigation.
Action Planned (AI summary) Sherwood Forest Hospitals NHS Trust has determined that following referral of Mrs. S to the vascular team, a letter was sent to Mrs. Stokes on 15 July 2015. Following this case, patient contact information has been reviewed. Further to the investigations referred to, Mrs S’ case is to be discussed at the next vascular Morbidity and Mortality meeting at NUH. The legal team is to be made part of the Governance Directorate, with offices adjacent to enable a greater working relationship. The Radiology Department will review and modify its XXXX policy to take account of electronic reporting and a referrer acknowledgement system.
Harold Davies
All Responded
2016-0185 13 May 2016
A-ONE+ Highways England Nottinghamshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns about the national speed limit on the approach and insufficient warning signs.
Noted (AI summary) Highways England has discussed the coroner's report with relevant parties and is seeking funding for an accident remedial scheme designed by AOne+ involving interactive signs, clearer markings, and improved signage. They cleared vegetation around the junction to improve visibility and aim to deliver the scheme within the next year if funds are approved. A-one+ acknowledges the coroner's concerns and states that they have made safety recommendations to Highways England regarding the junction. However, they state that it is Highways England's responsibility to secure funding for improvements. A-one+'s contract for the area expired on July 1, 2016 and it no longer has responsibility for the site. Nottinghamshire County Council acknowledges the coroner's concerns regarding accidents at the A46/Station Road junction but states that the Trunk Road is the responsibility of Highways England, and they defer to Highways England's proposed measures. They do not consider a speed limit reduction on Station Road to be effective or appropriate.
Douglas Kay
All Responded
2016-0033 5 Feb 2016
Doncaster and Bassetlaw Hospital NHS Fo…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.
Action Planned (AI summary) The Trust developed an Upper GI Bleed Transfer Policy for Bassetlaw Hospital after consultation between anaesthetic and medical teams. Staff will be made aware of the policy, and it will be ratified at the next Patient Safety Review Group meeting for wider dissemination.
Emma Carpenter
All Responded
2015-0276 14 Jul 2015
Department for Education Department of Health and Social Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.
Action Taken (AI summary) The Department of Health provided NHS England with £7 million in 2014/15 to increase CAMHS Tier 4 bed provision and improve access. Health Education England plans to commission 340 training places for school nurses in 2015-16, representing a 71.7% increase, and will review curriculums to include recognised areas of health. NHS England has invested in inpatient CAMHS beds, developed national service specifications for acute inpatient mental health units, and is planning to commission inpatient beds based on need. They highlight the MindEd e-portal and are piloting a single point of access programme for CAMHS and schools. The Trust has communicated with Nottinghamshire Health Care Foundation Trust, offering a formal service level agreement and a named consultant to support patients from the Bassetlaw area receiving treatment at Thorneywood Adolescent Unit. Although not required, the Trust has identified a consultant and will actively engage with Nottinghamshire Healthcare Trust as needed.
Lydia Corah
All Responded
2015-0181 11 May 2015
Nottingham University Hospitals NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Action Taken (AI summary) Enhanced induction training has been implemented to reduce patient identification errors. The RCA generated an action plan that included reflection by the member of staff involved and updating of checking procedures.
Philip Robinson
All Responded
2015-0225 13 Mar 2015
Doncaster and Bassetlaw Hospitals NHS F…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.
Action Taken (AI summary) The Trust completed an "observations project" including documentation of EWS on discharge and implemented a safety brief at shift changes. They are also planning to implement the i-Hospital whiteboard system and broaden advanced nurse practitioner roles.
Elizabeth Cox
All Responded
2015-0094 12 Mar 2015
Sherwood Hospitals NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.
Action Planned (AI summary) The Trust is implementing a new staffing model on surgical wards with 5 RNs and 2 HCAs on days, and 3 RNs and 1 HCA on nights. Medical wards will transition to this model when nurse recruitment allows, anticipated in 12 months.
Phyllis Kerry
All Responded
2014-0457 23 Oct 2014
Nottingham University Hospitals NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
Action Planned (AI summary) A new guideline has been prepared to improve the management of anticoagulation in patients with intracerebral hemorrhage, clarifying specialty responsibilities. The specialties involved are currently consulting with colleagues to finalize the guideline, and it will be added to the NUH guideline app. A new guideline for treating warfarin patients with intracranial hemorrhage has been agreed and will be communicated to medical staff and included in specialty inductions. The guideline group will also consider including it in the NUH guideline app.
Beryl French
All Responded
2014-0198 30 Apr 2014
Lifestyle Care PLC
Care Home Health related deaths
Concerns summary (AI summary) Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Action Taken (AI summary) Life Style Care has provided updated training on DNACPR forms to staff across its remaining homes. An End of Life care plan has been piloted in 3 homes and is under consideration by the Quality Assurance team to be signed off by the end of September 2014.
Sally Perrons
All Responded
2014-0158 9 Apr 2014
Association of Ambulance Chief Executiv… East Midlands Ambulance Service NHS Tru…
Community health care and emergency services related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text for summarization.
Action Planned (AI summary) The National Ambulance Sector will require the use of either a digital ETC02 monitoring device or full waveform capnography for every intubation with immediate effect. Waveform capnography will be considered the gold standard and the sector is committed to having this in place on every responding vehicle crewed by a paramedic by July 2017.
Cynthia Fretwell
All Responded
2013-0366 16 Dec 2013
HAMA Medical Centre, NHS Commissioning …
Community health care and emergency services related deaths
Concerns summary (AI summary) The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication between staff and doctors.
Action Taken (AI summary) Hama Medical Centre has updated its Mental Capacity Act 2005 policy and updated its Telephone Consultation Protocol, in addition to discussing the Mental Capacity Act during medical meetings. They have also included a full assessment of the patient's mental capacity in a situation where they are refusing medical treatment or admission to hospital in accordance with guidelines in the Practice's mental capacity policy.