Staffordshire South
Coroner Area
Reports: 59
Earliest: Aug 2013
Latest: 1 Oct 2021
71% response rate (above 62% average).
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
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.
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
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.
Michael Dobson
All Responded
2021-0035
11 Feb 2021
HMP Dovegate
Mental Health related deaths
State Custody related deaths
Suicide (from 2015)
Concerns 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.
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
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.
Neil Barre
All Responded
2020-0237
17 Nov 2020
Staffordshire Fire and Rescue Service HQ
Other related deaths
Concerns 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.
Sylvia Griffiths
All Responded
2020-0238
17 Nov 2020
Staffordshire Fire and Rescue Service HQ
Other related deaths
Concerns summary
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
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
Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.
Liam Clark
All Responded
2020-0030
18 Feb 2020
Commissioner for Highways
Road (Highways Safety) related deaths
Concerns 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.
Marlon Watson
All Responded
2020-0010
14 Jan 2020
HMP Dovegate
State Custody related deaths
Suicide (from 2015)
Concerns 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.
Keith Whetton
All Responded
2019-0452
24 Dec 2019
Hunters Lodge Care Home
Care Home Health related deaths
Concerns 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.
Maureen Milton
All Responded
2019-0396
22 Nov 2019
Care Quality Commission
Public Health England
British Medical Association
+3 more
Other related deaths
Concerns 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.
Steffan Evans
All Responded
2019-0339
8 Oct 2019
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns 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.
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
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.
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
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.
Lindsey Bailey
All Responded
2019-0235
11 Jul 2019
Midlands Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
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
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
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
Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.
Kendall Chadwick
All Responded
2018-0352-wp26418
15 Nov 2018
Staffordshire County Council
Road (Highways Safety) related deaths
Jacob Brown
All Responded
2018-0187
19 Jun 2018
Department for Transport
Road (Highways Safety) related deaths
Concerns 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.
Adrian King
All Responded
2018-0061
27 Feb 2018
Foreign Office
Other related deaths
Concerns 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.
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
County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
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
Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
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
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.
Alan Stead
All Responded
2016-0261
22 Jul 2016
Care UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Mary Hyden
All Responded
2015-0251
1 Jul 2015
University Hospital North Midlands
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.