Staffordshire and Stoke on Trent

Coroner Area
Reports: 55 Earliest: Feb 2014 Latest: 3 Feb 2026

80% response rate (above 63% average).

Response Status
Responded 44 No Response 1 Historic 10
AI Classification
Action Taken 39%
Action Planned 41%
Noted 18%
Disputed 2%
Based on 66 classified responses
Top Categories
Hospital Death (Clinical Procedure… (23) Road (Highways Safety) related dea… (12) Community health care and emergenc… (5) Suicide (from 2015) (5) Alcohol, drug and medication relat… (4)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: -19 reports · +16pp response rate
vs national average: -29 reports · +17pp response rate
Clear 34 results
Andrew McCall
All Responded
2019-0228 1 Jul 2019
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Action Planned (AI summary) NHS England will contact Addiction Dependency Solutions to review processes for collecting/verifying GP data and information sharing. They will also write to all Staffordshire GP practices to highlight risks and ask them to alert the clinic if they receive information relating to a patient not registered at the practice.
Peter Moran
All Responded
2019-0181 30 May 2019
AR1 Homecare Limited
Community health care and emergency services related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.
Action Taken (AI summary) The organisation provides staff training on fire awareness, uses risk assessment tools for client homes and staff induction, and has engaged a company for risk assessments and online fire training. They added a clause to their risk assessment that under no circumstances do they remove any knobs from appliances, and recommend the request of a Fire Officer to visit.
Geoffrey Duke
All Responded
2019-0256 30 May 2019
Darwin medical Practice University Hospitals Birmingham NHS Tru… University Hospitals of Derby and Burton
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.
Noted (AI summary) The trust has developed a Cardiac Implantable Electronic Device Lead Infection Microbiology Hospital Guideline to aid in detection and treatment of Subacute Bacterial Endocarditis (SBE) related to cardiac rhythm devices and will link it to existing guidance for Pyrexia of Unknown Origin (PUO). The learning board has been shared and will be further supported at the Trust-wide Quality Summit and in a monthly 'Patient Safety Brief' newsletter. The practice discussed the case and reviewed the patient's medical record, concluding that the diagnosis was difficult to make in primary care due to the unusual nature of the infection and non-specific symptoms. They now recognise this as a possible cause of malaise in similar future scenarios. The Trust is undertaking a programme of education for acute physicians via grand rounds and a 'Lesson of the Month' email to raise awareness of pacemaker related endocarditis. They will also update patient information leaflets to include additional instructions regarding fever and device related endocarditis, aiming to complete this by November 2019.
Reginald Key
All Responded
2018-0025 24 Jan 2018
Staffordshire Clinical Commissioning Gr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during transit.
Action Planned (AI summary) The CCG has instructed the provider to produce an action plan to review incident recording mechanisms, establish procedures to cross-check journey times, and identify actions to improve communication with patients and relatives; this plan will be reviewed at the next provider contract meeting in April 2018.
Donald Till
All Responded
2018-0013 11 Jan 2018
University Hospitals of North Midlands
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.
Action Planned (AI summary) The evidence base regarding risk assessment for patients with bowel obstruction will be presented to clinicians at the departmental mortality and morbidity meeting, to remind them to ensure the surgical teams gave similarly considered the risk benefit for a nasogastric tube when booking cases for CEPOD (emergency) theatre.
Derek Nixon
All Responded
2016-0103 10 Mar 2016
Staffordshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision and highlighting pedestrian visibility issues for large vehicles.
Action Planned (AI summary) Staffordshire County Council proposes to not reinstate a 'Keep Clear' marking and install a short section of guardrail at the junction of Ball Haye Street and Fountain Street in Leek. These measures are proposed to be funded from the 2016/17 financial year Capital Programme.
John Lomas
All Responded
2015-0396 1 Oct 2015
Sports Camp Tirol
Service Personnel related deaths
Concerns summary (AI summary) Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.
Disputed (AI summary) Sport Camp Tirol disputes several factual points in the coroner's report, asserts its guides acted appropriately, and blames the army for allowing a non-swimmer on the trip. It will require evidence of swimming qualifications from participants in the future, and says that the HYDRO Company are now obligated to inform the rafting companies well in advance about "stowage discharge".
Stephen Richardson
All Responded
2015-0507 18 Aug 2015
University Hospital of North Staffordsh…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of aspiration.
Action Planned (AI summary) The ward will look to implement a nurse 'champion' for patients attending with learning disabilities in the future.
Arthur Fry
All Responded
2015-0258 7 Jul 2015
University Hospital of North Staffordsh…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Action Planned (AI summary) University Hospitals of North Midlands NHS Trust is incorporating a phrase into the MRI safety questionnaire about MRI compatibility. The Department of Imaging has applied for transformation funding for Imaging Assistants to visit patients on the ward pre-scan. Escort nurses have a written handover on return to the ward from MRI.