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
Clear 34 results
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.
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.
Joseph Drew Whiteside
All Responded
2013-0377 16 Dec 2013
East Staffordshire Borough Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access points.
Action Planned (AI summary) East Staffordshire Borough Council appointed the Royal Society for the Prevention of Accidents (RoSPA) to conduct inland water safety reviews across Burton-upon-Trent and Uttoxeter and will be acting upon their recommendations as soon as practicable.
Elsie May Treece
All Responded
2013-0376 16 Dec 2013
Burton Hospitals NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Action Taken (AI summary) Burton Hospitals NHS has always provided training for staff in relation to incident reporting, and they have arranged to provide additional training and support for Ward 6. They have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting.
Ronald Ellwood
All Responded
2013-0222 15 Aug 2013
Queen’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided concerns text is too truncated to identify specific safety issues.
Action Planned (AI summary) The Trust plans to refurbish the Air Conditioning Systems within the hospital, re-evaluating environmental conditions and the system design to control the environment with additional heat loads, especially in the ITU unit.