Staffordshire and Stoke on Trent
Coroner Area
Reports: 68
Earliest: Feb 2014
Latest: 3 Feb 2026
74% response rate (above 62% average).
Lynsey Dearden
All Responded
2025-0589
18 Nov 2025
NHS England
North Staffordshire Combined Healthcare…
Suicide (from 2015)
Concerns summary
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for appointments or initial assessments.
Action taken summary
NHS England has shared draft national guidance, the Personalised Care Framework, with systems for early adoption, which sets out core principles for care plans, therapeutic relationships, and access t
Christopher Bradbury
All Responded
2025-0134
11 Mar 2025
Royal Stoke University Hospital
NHS England
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an audit trail for omitted medication doses, creates significant patient safety risks.
Action taken summary
NHS England will seek to ensure emphasis on escalation of deteriorating patients within statutory and mandatory training for infection and prevention control this year. For national guidelines on seve
Philip Unwin
All Responded
2025-0095
19 Feb 2025
Royal Stoke University Hospital
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for patient-to-nurse ratios.
Action taken summary
NHS England reports that Royal Stoke University Hospital has implemented new pathways for Acute Medicine in ED Same Day Emergency Care, introduced a daily ED Huddle and a 'Senior Decision …
Kevin O’Reilly
All Responded
2025-0088
17 Feb 2025
Highways England
Road (Highways Safety) related deaths
Concerns summary
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
Action taken summary
National Highways confirms that radar stopped vehicle detection (SVD) technology is in place on all operational all lane running (ALR) motorways, and all recommendations from the smart motorway stockt
Eleanor Curley-Bennett
All Responded
2024-0705
20 Dec 2024
Festimed
Child Death (from 2015)
Concerns summary
There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.
Action taken summary
The CQC states that care provided at events falls outside its regulatory remit and notes that Festimed Ltd went into voluntary liquidation. However, CQC has reviewed and updated its registration …
Anne Leake
All Responded
2024-0696
16 Dec 2024
University Hospitals of North Midlands …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable to human error.
Action taken summary
The Trust has implemented daily Ward Round Boards, a new surgical board with MDT outcome fields, and a new Cardiology/Thoracic Critical Pathway to improve communication. They have also reintroduced we
Gemma Ralph
All Responded
2024-0613
8 Nov 2024
Cannock Chase Hospital
NHS England
Alcohol, drug and medication related deaths
Concerns summary
Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.
Action taken summary
NHS England refers to existing professional guidance for safe medicine handling and states it will continue to explore and support improvements in controlled access to medicines. They refer the Corone
Phyllis Hart
All Responded
2024-0563
16 Oct 2024
County Hospital Stafford
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.
Action taken summary
The Trust clarifies that a 24/7 vascular on-call service is available via Royal Stoke and surgeons are on-site at County Hospital weekdays. They will ensure information on how to urgently …
Alix Knowles
All Responded
2024-0528
2 Oct 2024
Derby and Burton Hospital
Royal Stoke University Hospital
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Action taken summary
NHS England deferred the concern about bank staff access to patient notes to individual healthcare providers. For the issue of different NHS Trusts being unable to access patient notes, NHS …
Elizabeth Bury
All Responded
2024-0480
28 Aug 2024
Staffordshire Moorlands District Council
Other related deaths
Concerns summary
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
Action taken summary
The Council will remove existing speed bumps and replace them with a larger, flat-top speed bump that will be painted as a zebra crossing and adjoin pedestrian platforms, with work …
Kial Thurman
All Responded
2024-0454
13 Aug 2024
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns summary
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too high, posing a risk of future deaths.
Action taken summary
The Council conducted a site visit, analysed collision data, and assessed traffic speeds. They concluded existing safety features are adequate and disputed the need for a speed limit reduction, citing
Brogen-Lea Storey
All Responded
2024-0404
24 Jul 2024
Road Safety Management Staffordshire Co…
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there are no measures to prevent pedestrians walking into traffic or to allow safe crossing.
Action taken summary
Staffordshire County Council has established highway maintainable at public expense, conducted a site visit with Cannock District Council, and analysed historical road traffic collision data. They are
Glennis Connelly
All Responded
2024-0293
31 May 2024
Department of Health and Social Care
University Hospitals of Derby and Burto…
Alcohol, drug and medication related deaths
Concerns summary
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible across different sites.
Jamie Pilkington
All Responded
2024-0101
22 Feb 2024
Midlands Partnership Foundation Trust
Mental Health related deaths
Road (Highways Safety) related deaths
Concerns summary
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system changes were assured to prevent future omissions.
Kathleen Booth
All Responded
2023-0462
22 Nov 2023
NHS England
Royal Stoke University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients with injuries sustained on Fridays.
Myra Maxfield
All Responded
2023-0396
25 Oct 2023
NHS England
University Hospital’s of North Midlands
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.
Sandra Finch
All Responded
2023-0183
9 May 2023
NHS England and West Midlands Ambulance…
Emergency services related deaths (2019 onwards)
Concerns summary
Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.
Sara Jones
All Responded
2023-0118
15 Apr 2023
Royal Stoke University Hospital and Bet…
Road (Highways Safety) related deaths
Concerns summary
A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.
Minaal Salam
All Responded
2023-0145
13 Feb 2023
Stoke on Trent City Council
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Eirwen Hollister
All Responded
2022-0314
11 Oct 2022
Heathview Medical Practice
Emergency services related deaths (2019 onwards)
Concerns summary
The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Shaun Mansell
All Responded
2021-0383
1 Nov 2021
Royal Stoke University Hospital and NHS…
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.
Sky Rollings
All Responded
2021-0354
16 Oct 2021
North Staffordshire Combined Healthcare
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary
The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.
Adam Forrester
All Responded
2021-0268
11 Aug 2021
WISH and Health and Safety Executive
Alcohol, drug and medication related deaths
Other related deaths
Concerns summary
A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk for vulnerable individuals.
Rebecca Pykett
All Responded
2021-0264
17 Jul 2021
NHS England
North Staffordshire Combined Healthcare…
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary
The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.
Zainab Hashim and Tafaoul Abdulkarim
All Responded
2021-0205
16 Jun 2021
Stoke-on-Trent City Council
Child Death (from 2015)
Community health care and emergency services related deaths
Other related deaths
Concerns summary
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.