Coventry
Coroner Area
Reports: 69
Earliest: Sep 2013
Latest: 7 Apr 2026
64% response rate (above 63% average).
George Watson
Historic (No Identified Response)
2016-wp25378
19 Aug 2016
University Hospital, Coventry
University Hospitals Coventry and Warwi…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
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.
Stanley Sampey
Historic (No Identified Response)
2016-0191
18 May 2016
George Eliot Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.
Mark Seward
Partially Responded
2016-0136
5 Apr 2016
AGD Equipment Limited
Construction Plant Hire Association
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety risks.
Action Taken
(AI summary)
The company has reminded staff about the health and safety policy, reviewed the site safety induction, and introduced a new traffic management plan. They have also invested in new health and safety software and appointed a new Safety Officer/Assistant Manager.
Peter Embra
Historic (No Identified Response)
2016-0087
1 Mar 2016
Warwickshire County Council
Community health care and emergency services related deaths
Concerns summary (AI summary)
A local authority failed to act on an urgent GP referral for a patient assessment, leading to a significant one-week delay before a social worker visit.
Eileen Thompson
Partially Responded
2016-0051
15 Feb 2016
George Eliot Hospital NHS Trust
NHS England
Welsh Government
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk of the bed moving and potentially injuring patients.
Disputed
(AI summary)
ArjoHuntleigh disputes the need for further action, stating that the root cause was the combination of device use and the patient's health state, and that current warnings are adequate. They conducted a simulation and PMS review but found no similar incidents globally. NHS Improvement will work with the College of Occupational Therapists and other stakeholders to drive the development of new national resources. Once new resources are available, they will explore the option of issuing a stage 2 alert to signpost to the new resources.
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.
Mark Burdett
Historic (No Identified Response)
2015-0005
9 Jan 2015
Warwickshire City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular direction.
Amar Majid
Historic (No Identified Response)
2014-0495
11 Nov 2014
Coventry City Council
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Evelyn Smith
Historic (No Identified Response)
2014-0406
12 Sep 2014
Health Education England
NHS England
Royal College of Emergency Medicine
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
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.
Sean Morley
Historic (No Identified Response)
2014-0132
24 Mar 2014
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.
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.
Mary Waldron
Historic (No Identified Response)
2014-0127
10 Jan 2014
Care Quality Commission
Nursing and Midwifery Council
St Mary’s Nursing Home
+1 more
Care Home Health related deaths
Concerns summary (AI summary)
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
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.
Caroline Lee
Historic (No Identified Response)
2013-0228
11 Sep 2013
University Hospital Coventry and Warwic…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.