Staffordshire South

Coroner Area
Reports: 59 Earliest: Aug 2013 Latest: 1 Oct 2021

71% response rate (above 63% average).

Response Status
Responded 42 Historic 17
AI Classification
Action Taken 31%
Action Planned 43%
Noted 24%
Disputed 2%
Based on 49 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Road (Highways Safety) related dea… (10) Other related deaths (9) Mental Health related deaths (9) Alcohol, drug and medication relat… (8)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: -15 reports · +7pp response rate
vs national average: -25 reports · +8pp response rate
59 results
Derek Smith
Historic (No Identified Response)
2018-0186 19 Jun 2018
Virgin Care Services Limited
Care Home Health related deaths
Concerns summary (AI summary) Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Matthew Gayle
Historic (No Identified Response)
2018-0092 27 Mar 2018
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a missed histology opportunity.
Adrian King
All Responded
2018-0061 27 Feb 2018
Foreign Office
Other related deaths
Concerns summary (AI summary) British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care outcomes.
Action Taken (AI summary) The FCO has reminded consular staff of policy guidance and best practices to ensure timely action. Since July 2017, all consular calls are answered at in-house Consular Contact Centres providing a 24/7 service. They are also encouraging British travellers to take out appropriate travel insurance before they travel.
John Edwards
Partially Responded
2018-0015 10 Jan 2018
Community Disability Nurse Independent Futures, Southwinds Care Ho…
Care Home Health related deaths
Concerns summary (AI summary) The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Disputed (AI summary) Response Southwinds Limited disputes the implication that neglect contributed to the death of Mr. Edwards, argues that other evidence was not sufficiently taken into account, and asserts that they were not given full pre-admission information.
Gwendoline Halfpenny
All Responded
2017-0353 5 Dec 2017
University Hospitals North Midlands NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
Action Planned (AI summary) The Trust will re-share and re-communicate the SOP regarding consultant referrals to all staff. A Deputy Medical Director has been appointed with specific responsibility for County Hospital to speed up resolution of any remaining issues.
Edna Collett
Historic (No Identified Response)
2017-0426 28 Nov 2017
North Midlands NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.
Frederick Dudley
Historic (No Identified Response)
2017-0272 16 Aug 2017
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a bend, and near a speed limit change, creating significant visibility and safety risks for pedestrians.
Dean Rowland
All Responded
2017-0208 27 Jun 2017
Peel Medical Practice South Staffordshire and Shropshire Heal…
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Noted (AI summary) The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information. Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.
Ondrej Suha
Historic (No Identified Response)
2017-0098 30 Mar 2017
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.
Lester Stacey
Historic (No Identified Response)
2017-0084 10 Mar 2017
South Staffordshire and Shropshire NHS …
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.
Annabel Lewis
Historic (No Identified Response)
2017-0085 9 Mar 2017
Child and Adolescent Mental Health Serv… South Staffordshire and Shropshire NHS …
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.
Roy Lawton
All Responded
2016-0441 9 Dec 2016
Marks and Spencer
Community health care and emergency services related deaths Product related deaths
Concerns summary (AI summary) The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.
Noted (AI summary) M&S expresses condolences and states that the Gown was compliant with all legal requirements. M&S goes significantly beyond the legal requirements in its flammability testing of adult dressing gowns.
Alan Stead
All Responded
2016-0261 22 Jul 2016
Care UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Action Taken (AI summary) Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning from the case at a National Quality and Improvement Meeting.
Angela Brealey
Partially Responded
2015-0473 24 Dec 2015
South Staffordshire and Shropshire NHS … St George’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Action Taken (AI summary) The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, with commissioners carrying out a challenge review.
Mary Hyden
All Responded
2015-0251 1 Jul 2015
University Hospital North Midlands
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.
Action Taken (AI summary) The University Hospitals of North Midlands NHS Trust has reviewed the consultant's job plan, which will be updated from October 2015 to allow for a better work-life balance. The consultant is also now supported by a second consultant and has been encouraged to use administrative support.
Irene Hamilton-Parker
All Responded
2015-0197 20 May 2015
Department of Business Innovation and S…
Product related deaths
Concerns summary (AI summary) Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Noted (AI summary) The Department for Business Innovation and Skills acknowledges concerns about clothing flammability but states that most clothing is flammable and reducing it would require flame retardants with their own risks. They don't believe there's sufficient evidence to extend flammability requirements to other types of clothing but will keep the issue under review.
Mark Groombridge
All Responded
2015-0142 17 Apr 2015
HM Prison and Probation Service
Other related deaths
Concerns summary (AI summary) There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Action Planned (AI summary) While the Director of Probation believes existing guidance on offender recall is clear, Deputy Directors will ensure probation staff are reminded of procedures by 31 August. The Public Protection Casework Section (PPCS) will issue a Senior Leaders Bulletin covering recall actions and will organise Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year.
Peter Wright
All Responded
2015-0073 2 Mar 2015
South Staffordshire and Shropshire NHS …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate out-of-hours doctor cover, relying on paramedics.
Action Taken (AI summary) The Trust undertakes nurse staffing establishment reviews every six months, using quality metrics and workload calculators. They also provide basic life support training to medical and nursing staff and have first aid equipment available.
Amanda Hawkins
Partially Responded
2014-0516 26 Nov 2014
Walsall and Dudley Mental Health NHS Tr… West Midlands Police
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Police related deaths
Concerns summary (AI summary) Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.
Action Planned (AI summary) The Trust will ensure outpatient letters from CRS North medical teams are copied to the care coordinator. A working group led by the Head of Recovery Services is looking at long-term solutions.
Hilda Cole
Historic (No Identified Response)
2014-0460 24 Oct 2014
Care Quality Commission Welbeing
Product related deaths
Concerns summary (AI summary) The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.
Kai Lambe
Historic (No Identified Response)
2014-0557 6 Oct 2014
Environment Agency Headquarters
Other related deaths
Concerns summary (AI summary) Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant risk.
Olegs Sulaimonovs
Partially Responded
2014-0375 14 Aug 2014
Billington Farm Staffordshire County Council Staffordshire Police +1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary) Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated area. Additionally, there was inadequate information and encouragement for reflective clothing among the migrant population.
Action Planned (AI summary) The employer will supply reflective vests to staff and recommend their use at night when walking on the A518, including this information in the induction process for 2015.
Adam Williams
All Responded
2014-0324 14 Jul 2014
HMP Featherstone
State Custody related deaths
Concerns summary (AI summary) Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential for further CCTV installation.
Action Taken (AI summary) HMP Featherstone now requires two healthcare staff to attend all health emergencies called over the radio. Duty Managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed by the Senior Management Team.
Mitchell Clifton
All Responded
2014-0227 13 May 2014
Casualty Reduction Team
Road (Highways Safety) related deaths
Concerns summary (AI summary) The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings or physical dividers.
Noted (AI summary) Staffordshire County Council reports that the Co-operative introduced road humps, lane markings, and a pedestrian route after the accident. The Co-operative has agreed to renew worn road markings, and the council will add further markings on the highway. The Department for Transport acknowledges the concerns but states that changes to vehicle requirements are not proposed, as they are not convinced that changes to existing requirements would necessarily prevent similar incidents.
Andrey Wakefield
All Responded
2014-0186 22 Apr 2014
University Hospital of North Staffordsh…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Action Planned (AI summary) A solution is being rolled out in three phases to improve communication of discharge information between the hospital and GPs, including remote implementation, training, IT support and standard operating procedures. They are awaiting confirmation from Western Cheshire, South East Staffs and Seisdon; Shropshire and Vale Royal and South Cheshire to commit to the plan.