Coventry
Coroner Area
Reports: 69
Earliest: Sep 2013
Latest: 7 Apr 2026
64% response rate (above 63% average).
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.
Luisa Mendes
All Responded
2016-0243
30 Jun 2016
Chief Constable of Warwickshire Police
Police related deaths
Concerns summary (AI summary)
Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.
Action Taken
(AI summary)
Warwickshire Police have trained staff on threat, harm, risk, and vulnerability using the National Decision Making model and are seeking to introduce a system change to alert priority incidents out of time. They are also in the advanced stages of procuring a new Command and Control system to include changes required as a result of the inquest.
Julios Catachanas
All Responded
2015-0174
1 May 2015
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.
Action Taken
(AI summary)
• Following notification of the collision, a Team Leader and 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 across the County.
Valerie Walton
All Responded
2015-0107
19 Mar 2015
Coventry City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The positioning of a pedestrian crossing on the apex of a sharp bend was a factor in the death, and the coroner suggested the crossing should be on a straight section of the road or controlled by traffic lights.
Action Planned
(AI summary)
Coventry City Council proposes to enhance the zebra crossing's conspicuity by installing more intensely illuminated Belisha beacon heads and illuminated poles, with work anticipated in the next three to six months.
Donna Kirkland
All Responded
2014-0341
25 Jul 2014
Coventry and Warwickshire Partnership T…
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.
Noted
(AI summary)
The Trust replaced wall-mounted alcohol-based hand sanitiser dispensers with alcohol-free alternatives and raised staff awareness of the risks associated with ingestion of alcohol. The Department of Health acknowledges the concerns and points to existing national guidance on suicide prevention and risk assessment in mental health services, but doesn't describe specific actions taken or planned in response to the report.
Ming Cheung
All Responded
2014-0332
15 Jul 2014
Tesco Plc
Road (Highways Safety) related deaths
Concerns summary (AI summary)
An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing to the incident and near-misses.
Action Taken
(AI summary)
• Vegetation growth was cut back during the first week of August 2013 and will continue to be routinely checked at six-monthly inspections.
• The SLL sign on the down line was moved from 4.9 meters to 3 meters on 8th August 2014.
• The SLL sign on the up side remains at 3.4 meters from the track due to troughing at the 3 meter point, but its current location is considered appropriate.
Amanda Richards
All Responded
2014-0228
12 May 2014
Whitefriars Housing
Other related deaths
Concerns summary (AI summary)
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Action Planned
(AI summary)
Whitefriars Housing states that they will participate in a serious incident review led by the West Midlands Fire Service, and will commission and pay for the installation of domestic sprinkler system to an individual dwelling if it is agreed as the appropriate action.
John Grooby
All Responded
2014-0054
7 Feb 2014
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.
Action Planned
(AI summary)
Warwickshire County Council will install two "Wild animals likely to be in the road" warning signs on the A3400, with an order raised on 12 February 2014 and an estimated installation time of 6-8 weeks.
Archibold Wellbelove
All Responded
2013-0324
4 Dec 2013
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware of footpath discontinuations.
Action Taken
(AI summary)
Warwickshire County Council has brought forward its review of night-lighting policy and will implement a dropped crossing point, barrier rail, supporting signage, and keep the street light on throughout the night where the footway terminates.