Coventry
Coroner Area
Reports: 69
Earliest: Sep 2013
Latest: 7 Apr 2026
64% response rate (above 63% average).
Robert Hammond
All Responded
2021-0409
6 Dec 2021
Coventry and Warwickshire Partnership T…
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.
Action Planned
(AI summary)
Coventry and Warwickshire Partnership NHS Trust is undertaking a project to improve risk assessment and management, including reviewing best practices, auditing current practices, commissioning a staff survey, and conducting observational studies. This will inform a review of policies, procedures, training and professional development.
Harbans Singh
All Responded
2021-0345
15 Oct 2021
Warwick Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.
Action Planned
(AI summary)
A working group reviewed discharge processes and thyroid blood test flagging. A new 'Discharge to Assess' process will be rolled out across the trust by April 2022, with compliance audits to follow.
Dorothy Seekings
All Responded
2021-0230
7 Jul 2021
Clifton Court Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Action Taken
(AI summary)
Crosscrown Ltd has implemented the CareDocs digital care management system, introduced "Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training", and enhanced the agenda for staff meetings to include behavioral issues and safeguarding.
Ann Mowbray
All Responded
2021-0129
30 Apr 2021
Christian Congregation of Jehova’s Witn…
Other related deaths
Concerns summary (AI summary)
The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.
Noted
(AI summary)
The Christian Congregation of Jehovah's Witnesses asserts that while they provide support to vulnerable adults, they do not formally bring them into their care, thus a formal policy is deemed unnecessary; they rely on Christian duty and scriptural guidance.
Katy Samuels
All Responded
2020-0282
11 Dec 2020
Chief Executive and Mental Health lead …
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Action Taken
(AI summary)
Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is also implementing structured handover meetings at shift changes and introducing competency-based training for staff.
Holly Chevassut
All Responded
2020-0303
2 Dec 2020
GRS Recovery
Other related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.
Action Taken
(AI summary)
GRS Recovery has removed the offending mirrors, and rotated the remaining mirrors to reduce the width of the vehicles.
Eleanor Sherman
All Responded
2020-0254
26 Nov 2020
Warwick Hospital
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were two misdiagnoses at Warwick Hospital despite the GP's instructions, compounded by systemic errors related to accessing electronic records.
Action Taken
(AI summary)
The Trust convened a Working Group to review the case, completed outstanding actions from the Root Cause Analysis (RCA) Investigation, and disseminated the revised Acute Headache Pathway Trust-wide.
Xuanze Piao
All Responded
2020-0230
11 Nov 2020
Coventry University
Railway related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
Action Planned
(AI summary)
Coventry University is undertaking a full review of its policy and procedures relating to students who are under the age of 18, expected to be complete by January 31, 2021. They have also put in place an additional process for responding when international students under 18 fail to engage with their course, including a face-to-face meeting with a welfare advisor.
Ashley Walker
All Responded
2020-0019
31 Jan 2020
West Midlands Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
Action Taken
(AI summary)
Following a communication error, WMAS has instructed all staff to remove the WISER app from work devices unless trained. They have also produced further guidance in relation to Individual Chemical Exposure (ICE) incidents.
Colin Beaumont
All Responded
2019-0449
19 Dec 2019
Warwick Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Action Planned
(AI summary)
The Trust will amend its Nasogastric Tube Insertion policy to mandate review of alternative feeding options after two unsuccessful attempts, will arrange a Grand Round discussion on balancing clinical risks and communication with patients regarding treatment futility, scheduled within the next six months.
Darren Cumberbatch
All Responded
2019-0289
16 Jul 2019
HM Prison and Probation Service
Other related deaths
Concerns summary (AI summary)
Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to missed opportunities for early recognition, de-escalation, and appropriate management.
Action Planned
(AI summary)
The National Probation Service plans to assess and develop a training package regarding acute behavioural disturbance (ABD) for approved premises staff, with rollout expected to start in early 2020.
Mylon Sheppard
Historic (No Identified Response)
2019-0025
17 Jan 2019
Coventry & Warwickshire Partnership Tru…
Coventry NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.
Laila Habibi and Daniel Ghafuri
Historic (No Identified Response)
2018-0285
13 Sep 2018
Warwickshire County Council
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing significant road safety risks.
Greg Hutchins
Historic (No Identified Response)
2018-0129
12 Sep 2018
Birmingham & Solihull Mental Health Tru…
Mental Health related deaths
Concerns summary (AI summary)
Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
Ruth Perkins
Historic (No Identified Response)
2018-0236
20 Jul 2018
Department for Health
Care Home Health related deaths
Concerns summary (AI summary)
A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
Tyrone Evans
Partially Responded
2018-0227
16 Jul 2018
Department for Transport
Driver and Vehicle Licensing Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary)
There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal head injuries.
Noted
(AI summary)
The Department for Transport acknowledges the coroner's concerns regarding quad bike safety and helmet use but states there are no immediate plans to make helmet use compulsory, though the position is under review. They note changes to casualty statistics are made as part of quinquennial reviews.
Neil Jones
All Responded
2018-0163
25 May 2018
Warwickshire County Council
Alcohol, drug and medication related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for a determined casualty reduction scheme.
Action Taken
(AI summary)
• Following notification of the collision, a Road Safety Engineer from the Traffic and Road Safety Group attended the site with the traffic Management Assistant from Warwickshire and West Mercia Police’s Road Safety Team.
• At the time of the inspection officers attending agreed that there were no immediate actions that needed to be undertaken.
• The County Council undertakes an annual review of all collision cluster sites and routes across the County to identify those with the worst collision records and where there is a pattern of causes which can be addressed by engineering measures.
Cyril Anderton
Historic (No Identified Response)
2018-0065
1 Mar 2018
George Eliot Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.
John Scallan
Historic (No Identified Response)
2017-0391
13 Nov 2017
Coventry and Warwickshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct proper in-room checks, relying instead on distant sightings.
Katherine Vanloo
All Responded
2017-0493
28 Sep 2017
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders or audit completion and quality, leading to the wrong repair being performed.
Action Taken
(AI summary)
The Highways Safety Inspectors now use handheld devices to upload pothole details directly into the County Council's database. The Highways team has direct access to Confirm which displays a dashboard for overdue works orders.
Robert Dymond
All Responded
2017-0333
25 Jul 2017
Coventry & Warwickshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness during subsequent assessments.
Disputed
(AI summary)
The Trust believes its current pathway for managing DVTs goes beyond minimum requirements and therefore they do not repeat proximal scans.
Ozeivo Akerele
All Responded
2017-0337
19 Jul 2017
West Midlands Police
Police related deaths
Concerns summary (AI summary)
Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were inadequate.
Action Planned
(AI summary)
The case will be referred to the National Missing Persons Operational Group to consider amending guidance around how a search is co-ordinated in similar cases. This will provide clarity around the tasking of the search, what is being searched for, and the accurate recording of the search.
Joleen Linton
Historic (No Identified Response)
2017-0136
25 Apr 2017
Coventry & Warwickshire Partnership NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.
Andrew Machin
Historic (No Identified Response)
2016-0349
7 Dec 2016
National Offender Management Service
Other related deaths
Concerns summary (AI summary)
Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.
Mark Yafai
Historic (No Identified Response)
2016-0403
9 Nov 2016
Office of The Police and Crime Commissi…
West Midlands Police
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.