Staffordshire South
Coroner Area
Reports: 59
Earliest: Aug 2013
Latest: 1 Oct 2021
71% response rate (above 63% average).
Stephen Barton
Historic (No Identified Response)
2021-0326
1 Oct 2021
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.
Amanda Dunn
All Responded
2021-0261
30 Jul 2021
Staffordshire Police
Alcohol, drug and medication related deaths
Mental Health related deaths
Police related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and potentially prevent future deaths.
Noted
(AI summary)
Staffordshire Police has commenced a criminal investigation into potential offences committed against Mrs. Dunn and is reviewing repeat cases of anti-social behaviour involving vulnerable people. They have also written to the Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board to understand if further information was known by partner agencies. Staffordshire Police provides an update that the case has been referred to the Independent Office for Police Conduct (IOPC) for an independent investigation.
Susan Adams
All Responded
2021-0116
21 Apr 2021
St George’s Hospital
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.
Noted
(AI summary)
MPFT acknowledges the concerns about commissioning difficulties for patients living near county boundaries, explains how they have worked with other trusts to provide care, and states that the matter has been forwarded to commissioners for consideration.
Michael Dobson
All Responded
2021-0035
11 Feb 2021
HMP Dovegate
Mental Health related deaths
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.
Action Taken
(AI summary)
HMP Dovegate has ensured there is an on-call facilities maintenance officer available to remedy electricity faults in cells during out-of-hours periods. Duty Managers have been reminded of their responsibility to contact the on-call officer and that electricity should not be left inactive for any period of time.
Kevin Lovatt
Partially Responded
2021-0012
15 Jan 2021
HM Prison and Probation Service
NHS England
Alcohol, drug and medication related deaths
Other related deaths
Concerns summary (AI summary)
National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to breathing.
Noted
(AI summary)
NHS England and NHS Improvement outline the commissioning of healthcare into prisons is done on a principle of equivalence. They state Advanced Life Support is not appropriate for healthcare professionals working in prisons, as it may lead to staff working outside of their registered professional clinical competencies.
Sylvia Griffiths
All Responded
2020-0238
17 Nov 2020
Staffordshire Fire and Rescue Service HQ
Other related deaths
Concerns summary (AI summary)
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.
Neil Barre
All Responded
2020-0237
17 Nov 2020
Staffordshire Fire and Rescue Service HQ
Other related deaths
Concerns summary (AI summary)
Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, and shared nationally, and will also be incorporated into their Olive Branch training sessions.
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
All Responded
2020-0236
17 Nov 2020
Housing of Vulnerable People (Building …
Other related deaths
Concerns summary (AI summary)
Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.
Noted
(AI summary)
The Secretary of State acknowledges the deaths and states that the government is committed to building safety, including a review of smoke alarm standards.
Gwilym Price
Partially Responded
2020-0141
10 Jul 2020
Midlands and Lancashire Commissioning S…
Stafford and Surrounds Clinical Commiss…
Mental Health related deaths
Concerns summary (AI summary)
A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals in other cases, although it did not affect this specific patient's treatment.
Action Taken
(AI summary)
CCGs have completed actions including linking the Midlands Partnership Foundation Team and the DQS Team, providing the updated referral form to the DQS Team, and uploading the correct referral form onto all GP Practice clinical systems. They also sent communications to GP Practices highlighting the need to report any incorrect referral forms and will produce an SOP for managing referral forms and dealing with Coroner Regulation 28 responses.
Robert Brown
All Responded
2020-0065
9 Mar 2020
National Offender Management Service
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Action Planned
(AI summary)
NHS England and NHS Improvement are leading a project with HMPPS to implement inter-operability between SystmOne and NOMIS to improve information sharing; Phase one is delayed until August 2020 due to COVID-19 priorities, and Phase three is expected in 2021. The Safer Custody Zone at Dovegate was formed in 2019, to facilitate information sharing between prison and healthcare staff.
Liam Clark
All Responded
2020-0030
18 Feb 2020
Commissioner for Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review of road layout, signage, and safety improvements at the A5 junction.
Noted
(AI summary)
Highways England reviewed the A5 junction with Streetway Road and concluded that no improvements are warranted at this time. The junction will be routinely monitored for collisions and the condition of highways assets. The Department for Transport will review advice in driver learning materials and consider a hazard perception clip covering tail-swing for the driver theory test. They will also raise the marking of projections with the National Farmers' Union to remind them of the need to provide and maintain warning signs where required.
Marlon Watson
All Responded
2020-0010
14 Jan 2020
HMP Dovegate
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Action Planned
(AI summary)
Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites. Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight on ACCT and SASH training across all Care UK sites.
Keith Whetton
All Responded
2019-0452
24 Dec 2019
Hunters Lodge Care Home
Care Home Health related deaths
Concerns summary (AI summary)
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Action Taken
(AI summary)
Following a review of the coroner's report, staff have been supervised and completed falls training. The falls policy has been updated, and staffing levels have been increased to improve observation and patient safety.
Maureen Milton
All Responded
2019-0396
22 Nov 2019
British Medical Association
Care Quality Commission
Department of Health and Social Care
+3 more
Other related deaths
Concerns summary (AI summary)
There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.
Noted
(AI summary)
The MHRA has convened a stakeholder group to design educational resources for healthcare professionals and the public, aiming to launch a toolkit in 2020 with a press release and stakeholder propagation of key messages. NICE acknowledges the concerns but states that overseeing medicine safety, product warnings, and running safety awareness campaigns do not fall within its remit; they refer to existing BNF guidance for prescribers. Public Health England reviewed the report but defers to the Medical and Healthcare products Regulatory Agency (MHRA) as the concerns relate to medicines.
Evha Jannath
Historic (No Identified Response)
2019-0368
13 Nov 2019
Alton Towers
Drayton Manor Theme Park
Legoland
+3 more
Other related deaths
Concerns summary (AI summary)
The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.
Steffan Evans
All Responded
2019-0339
8 Oct 2019
County Highways Department
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, warranting a further review to improve road safety.
Noted
(AI summary)
Staffordshire County Council acknowledges the coroner's concerns regarding the B5017 Burton Road but states that collision data does not currently justify traffic calming measures. They are investigating if the road can be included in another funded scheme.
Maureen Jarvis
All Responded
2019-0357
11 Sep 2019
Midland Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.
Action Taken
(AI summary)
Midland Partnership NHS Trust circulated existing policies and SOPs to staff, provided bespoke training on physical health difficulties, developed an electronic dashboard for physical health assessments, secured regular input from an Advanced Nurse Practitioner, and reminded staff to record consent. A full action plan was developed and is enclosed.
Imran Mahmood
All Responded
2019-0355
4 Sep 2019
HM Prison and Probation Service
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.
Action Planned
(AI summary)
HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.
Lindsey Bailey
All Responded
2019-0235
11 Jul 2019
Midlands Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, potentially hindering her treatment and care.
Action Planned
(AI summary)
Midland Partnership NHS Trust is improving carer engagement by developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services, introducing a bespoke training programme for staff and is developing a letter for service users which outlines the importance of family involvement.
Maureen Martin
All Responded
2019-0220
26 Jun 2019
University Hospitals of Derby and Burto…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
Action Taken
(AI summary)
The Trust removed the nursing station desk on Ward 5 and provided staff with a "desk on wheels" to improve visibility. A walkaround review has been undertaken of all of the nursing stations/desks at Queens Hospital Burton and they are all positioned correctly.
Christopher Moss
Historic (No Identified Response)
2019-0066
26 Feb 2019
MOJ
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.
Richard Lockley
All Responded
2019-0010
10 Jan 2019
University of North Midlands Hospital N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.
Action Taken
(AI summary)
The Trust has reviewed the process for transfers between hospitals and is clarifying roles and responsibilities. They are also looking to 'RAG rate' all requests to transfer patients based on clinical need.
Kendall Chadwick
All Responded
2018-0352
15 Nov 2018
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The coroner recommends a review of a bend on the road close to Leese Hill, to see if additional safety steps would be advisable. The chevron boards were also in a dirty condition and there may be issues about maintenance.
Action Planned
(AI summary)
• The issue of monitoring blood plasma levels in people taking clozapine (or other antipsychotics) has been logged for consideration by the NICE guideline surveillance team undertaking the review process of clinical guideline CG178.
Thomas Jackson
Partially Responded
2018-0352-wp26415
13 Nov 2018
Department of Health and Social Care
Midlands Partnership NHS Foundation Tru…
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.
Action Planned
(AI summary)
• Officials have made enquiries with a number of bodies regarding routine therapeutic blood monitoring for patients prescribed clozapine.
• The NICE guideline CG178, which supports routine monitoring of physical health for people prescribed antipsychotic medication, is to undergo a surveillance review.
• The issue of monitoring blood plasma levels in people taking clozapine has been logged for consideration by the guideline surveillance team undertaking the review process.
Jacob Brown
All Responded
2018-0187
19 Jun 2018
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary)
There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to save lives.
Action Planned
(AI summary)
The Department for Transport is investigating the use of telematics as part of their £2 million research programme called ‘Driver 2020’. They also reference recent changes to legislation and campaigns targeting young drivers.