Coventry
Coroner Area
Reports: 66
Earliest: Sep 2013
Latest: 4 Mar 2026
58% response rate (below 62% average).
Peter Embra
Historic (No Identified Response)
2016-0087
1 Mar 2016
Warwickshire County Council
Community health care and emergency services related deaths
Concerns 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
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.
Julios Catachanas
Historic (No Identified Response)
2015-0174
1 May 2015
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns 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.
Valerie Walton
All Responded
2015-0107
19 Mar 2015
Coventry City Council
Road (Highways Safety) related deaths
Concerns summary
A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It should be moved to a straight section or controlled by traffic lights.
Mark Burdett
Historic (No Identified Response)
2015-0005
9 Jan 2015
Warwickshire City Council
Road (Highways Safety) related deaths
Concerns 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
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
Royal College of Paediatrics and Child …
Royal College of Emergency Medicine
NHS England
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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
Department of Health and Social Care
Coventry and Warwickshire Partnership T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Ming Cheung
Historic (No Identified Response)
2014-0332-wp24368
15 Jul 2014
Tesco Plc
Road (Highways Safety) related deaths
Concerns 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.
Amanda Richards
All Responded
2014-0228
12 May 2014
Whitefriars Housing
Other related deaths
Concerns summary
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Sean Morley
Historic (No Identified Response)
2014-0132
24 Mar 2014
Warwickshire County Council
Road (Highways Safety) related deaths
Concerns 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
A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.
Mary Waldron
Historic (No Identified Response)
2014-0127
10 Jan 2014
Care Quality Commission
St Mary’s Nursing Home
West Midlands Ambulance Service Univers…
+1 more
Care Home Health related deaths
Concerns 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
Road (Highways Safety) related deaths
Concerns 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 summary
Warwickshire County Council has brought forward a review of its night-lighting policy and decided to implement several changes at a footpath termination point. These include installing a dropped cross
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
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.
Man Ng
Partially Responded
2025-0614
[REDACTED] President of The Royal Colle…
[REDACTED] President of The Royal Colle…
President of The Royal College of Radio…
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.