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
Paul Hardy
Historic (No Identified Response)
2015-0041 4 Feb 2015
Nottinghamshire Healthcare NHS Trust
State Custody related deaths
Concerns summary Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Rebecca Overy
Historic (No Identified Response)
2014-0535 17 Dec 2014
Department of Health and Social Care
Other related deaths
Concerns summary An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.
John Wright
Historic (No Identified Response)
2014-0494 13 Nov 2014
Network Rail Rail Maritime and Transport Union Rail Accident Investigation Branch +1 more
Accident at Work and Health and Safety related deaths
Concerns summary Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. There was also a concern about balancing hearing protection with the ability to hear oncoming trains.
Patricia Mellor
Historic (No Identified Response)
2014-0491 12 Nov 2014
Medicines and Healthcare Product Regula… Derby Hospitals NHS Foundation Trust National Patient Safety Agency +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.
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 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.
Emma Lifsey
Historic (No Identified Response)
2014-0204 7 May 2014
Network Rail
Railway related deaths
Concerns summary Outdated, dim level crossing lights, inadequate research into sun glare, and a dangerously slow pace of upgrading equipment pose a significant ongoing risk to safety.
Beryl French
All Responded
2014-0198 30 Apr 2014
Lifestyle Care PLC
Care Home Health related deaths
Concerns 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.
Sally Perrons
All Responded
2014-0158 9 Apr 2014
East Midlands Ambulance Service NHS Tru… Association of Ambulance Chief Executiv…
Community health care and emergency services related deaths
Concerns summary No specific concerns were detailed in the provided text for summarization.
Cynthia Fretwell
Partially Responded
2013-0366 16 Dec 2013
Ministry of Justice NHS Commissioning Board Derbyshire and … HAMA Medical Centre
Community health care and emergency services related deaths
Concerns 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 summary Hama Medical Centre has updated its Mental Capacity Act 2005 Policy and its Telephone Consultation Protocol, circulating these to all staff. The practice has also held medical meetings to update …
Harold Elvidge
Historic (No Identified Response)
2013-0274 24 Oct 2013
Nottingham University Hospitals NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
Morris Reddington
All Responded
2021-0312
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be missed and delaying correct patient pathways.
Action taken summary NHS England has established a national Stroke Programme to address geographical disparity in thrombectomy access, which has already rolled out 24/7 capability to 19 sites across 8 networks. The progra
Keith Nottle
All Responded
2022-0189
Nottinghamshire Healthcare Trust and Tu…
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns 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 taken summary Turning Point has reviewed and refreshed the role of helpline workers, agreed a new Standard Operating Procedure for referrals to the Crisis Team, introduced additional monitoring and audits, and deve