Staffordshire South
Coroner Area
Reports: 59
Earliest: Aug 2013
Latest: 1 Oct 2021
71% response rate (above 63% average).
Norma Sheppard
Historic (No Identified Response)
2014-0129
21 Mar 2014
Queens Hospital Burton Upon Trent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Peter Banks
Historic (No Identified Response)
2014-0124
17 Mar 2014
Casualty Reduction Team
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and the crossing moved further into Westhead Avenue to improve safety.
Daniel Taylor
Historic (No Identified Response)
2014-0125
17 Mar 2014
Casualty Reduction Team
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review to prevent future collisions.
Pauline Meredith
Partially Responded
2014-0011
10 Jan 2014
Browning Street Surgery
General Medical Council
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Action Planned
(AI summary)
The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health and wellbeing of their vulnerable patients with complex mental health needs.
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.
Rachael Dallison
Historic (No Identified Response)
2013-0205
16 Sep 2013
Commissioner for Transport
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The provided concerns text is too truncated to identify specific safety issues.
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.
Ethel Smith Leese
Historic (No Identified Response)
2013-0184
7 Aug 2013
Stafford Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.