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
138 results
John Lowe
Historic (No Identified Response)
2015-0132 1 Apr 2015
Nottinghamshire Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
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.
Paul Hardy
Historic (No Identified Response)
2015-0041 4 Feb 2015
Nottinghamshire Healthcare NHS Trust
State Custody related deaths
Concerns summary (AI 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 (AI 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
Frisbys Solicitors Kennedys Solicitors Network Rail +3 more
Accident at Work and Health and Safety related deaths
Concerns summary (AI 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
Derby Hospitals NHS Foundation Trust Medicines and Healthcare Product Regula… National Institute for Health and Care … +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (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.
Emma Lifsey
Historic (No Identified Response)
2014-0204 7 May 2014
Network Rail
Railway related deaths
Concerns summary (AI summary) The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less than half as bright as they should have been and that the replacement of these lights with LEDs at level crossings was taking too long, given the known issue of sun glare affecting signal visibility.
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.
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 (AI 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.