Staffordshire South
Coroner Area
Reports: 59
Earliest: Aug 2013
Latest: 1 Oct 2021
71% response rate (above 63% 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 (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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.