Worcestershire

Coroner Area
Reports: 83 Earliest: Sep 2013 Latest: 1 Apr 2026

77% response rate (above 63% average).

83 results
Lucy Phelan
No Identified Response
2026-0209 1 Apr 2026
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; the manufacturer no longer recommends its use on Emergency Department monitors.
Surendrakumar Patel
No Identified Response
2026-0141 10 Mar 2026
Government Legal Department Midlands Partnership NHS Foundation Tru… Practice Plus Group
Community health care and emergency services related deaths
Concerns summary (AI summary) Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
John Franklin
All Responded
2026-0110 8 Feb 2026
Worcestershire County Council
Community health care and emergency services related deaths
Concerns summary (AI summary) A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Action Taken (AI summary) • The council has reviewed its policy and procedures for hospital discharge. • Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge. • The council will share with acute colleagues and the person/representative when AT is deemed necessary for a safe discharge and will arrange it in advance.
Emmett Morrison
All Responded
2026-0071 6 Feb 2026
Prison, Probation and Reducing Offending Probation and Reducing Offending, Minis…
State Custody related deaths
Concerns summary (AI summary) HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Action Planned (AI summary) • HMPPS is investing over £40 million in physical security measures across 34 prisons in the 2025/26 financial year. • This includes £10 million on anti-drone measures such as window replacements, external window grilles and specialist netting across 15 priority prisons, including HMP Long Lartin. • The Crime in Prisons Taskforce has been established to work closely with police and the CPS to improve the prosecution of those conveying contraband.
George Ritchie
All Responded
2026-0039 21 Jan 2026
Cardinal Healthcare
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Action Taken (AI summary) • The Home Manager was placed into disciplinary proceedings for failing to uphold policy, maintain effective oversight, and ensure compliance.
George Ritchie
No Identified Response
2026-0039-wp117787 21 Jan 2026
Cardinal Healthcare
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Jean Waldron
All Responded
2026-0009 8 Jan 2026
Ignite Health and Homecare Services
Care Home Health related deaths
Concerns summary (AI summary) An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.
Action Taken (AI summary) The agency has reinforced guidance to staff clarifying that wound care is outside their scope, issued formal reminders about escalating clinical concerns, and reviewed supervision processes to ensure adherence to scope-of-practice boundaries.
Mesut Olgun
All Responded
2025-0618 10 Dec 2025
HM Prison and Probation Service Probation and Reducing Offending, Minis…
Suicide (from 2015)
Action Planned (AI summary) HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.
Timothy Reading
All Responded
2026-0101 21 Nov 2025
Birmingham and Solihull Mental Health F… NHS England
Suicide (from 2015)
Concerns summary (AI summary) The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components for S.117 plans.
Noted (AI summary) • The Trust has a form within Rio which clearly sets out the relevant areas for the s.117 meeting and ensures that both healthcare and social care are signed up to the plan. • All staff in Acute care have been made aware of the form and the need to complete it.
William Roath
All Responded
2025-0518 14 Oct 2025
University Hospitals Birmingham NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors to prevent recurrence are still outstanding.
Action Taken (AI summary) UHB has delivered communication in the form of a Patient Safety Notice to all patient-facing staff to improve communications on SALT referrals. They have also taken steps to improve the comprehensive training of doctors in relation to recognising and acting upon swallowing problems and to strengthen the wider clinical governance framework around safe swallowing.
John Franklin
No Identified Response CC
2025-0474 16 Sep 2025
Worcestershire County Council
Other related deaths
Concerns summary (AI summary) A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety post-discharge.
Margaret Medlicott
All Responded
2025-0398 1 Aug 2025
Capital Care Group
Care Home Health related deaths
Concerns summary (AI summary) A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.
Action Taken (AI summary) The care group has implemented several changes, including revising its admissions policy, conducting mandatory training on challenging behaviour, implementing a new PCS training schedule, and conducting internal and organizational audits of care documentation. They also have updated the homes E-learning resources to cover updated expectations.
Jordanne Roberts
All Responded
2025-0326 26 Jun 2025
Worcestershire Acute Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.
Action Taken (AI summary) Worcestershire Acute Hospitals NHS Trust discussed the learning from the investigation via teaching and board rounds, sent an email containing this learning to all doctors including locums, and circulated a lesson of the week reminding staff of the need to read both parts of a CT scan report.
Vera Fortey
All Responded
2025-0312 19 Jun 2025
Green Range Limited
Care Home Health related deaths
Concerns summary (AI summary) Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Action Taken (AI summary) The care home implemented an action plan addressing management of falls, record keeping, and staff training, including fall prevention training and training on the Care Docs Portal. The manager who was in post prior to September 2024 returned to her role as Care Home Manager in May 2025.
Katrina Insleay
All Responded
2025-0084 6 Feb 2025
Herefordshire and Worcestershire Health… Worcestershire Acute Hospitals Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed follow-up and increased wound infection.
Action Taken (AI summary) The Trust is granting access to the Acute Trust's Electronic Patient Record ('Sunrise') for triage staff in Neighbourhood Teams and has developed a handover form detailing wound care advice to be sent home with patients.
Vauna Leeming
All Responded
2025-0033 17 Jan 2025
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Action Taken (AI summary) Worcestershire Acute Hospitals NHS Trust is reinforcing the direction that staff must sign prescription charts, updating and recirculating the lesson of the week on mechanical thromboprophylaxis, and requesting electronic prescribing charts meet all requirements. Divisions will undertake local regular audits to check compliance with signing prescription charts and provide monthly VTE compliance reports.
Edith Pye
All Responded
2024-0706 20 Dec 2024
Care UK Ltd
Care Home Health related deaths
Concerns summary (AI summary) The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.
Action Taken (AI summary) Care UK has implemented a revised Safety Incident Response Framework (SIRF) policy based on the NHS framework, introduced in September 2024, to place responsibility for investigating serious incidents on independent Home Managers. They have also improved the process for updating care plans and handover sheets and ensured regular monitoring by the Home Manager.
Teresa Auriemma
All Responded
2024-0633 14 Nov 2024
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.
Action Planned (AI summary) Worcestershire Acute Hospitals NHS Trust sent an advisory notice to doctors reminding them to prescribe IV fluids and monitor electrolytes as per NICE guidance, set up a working party to examine the reasons for non-compliance with these standards, reviewed the full suite of electrolyte correction policies, improved the visibility and search function of the Trust’s intranet page, and planned actions to get all doctors in the Trust to do CPD on electrolyte balance.
Henry Willems
All Responded
2024-0569 21 Oct 2024
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely leading to the deceased's preventable death.
Action Taken (AI summary) WMAS is increasing operational staff and ambulances, increasing paramedics and nurses in control rooms to improve 'Hear and Treat' rates, and using dynamic conveyancing to direct patients to hospitals with lower pressure. NHS England has commissioned an independent investigation of NHS performance with findings feeding into government's 10-year plan to radically reform the NHS.
Oliver Davies
All Responded
2024-0541 11 Oct 2024
Midlands Partnership NHS Foundation Tru…
Mental Health related deaths State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.
Action Taken (AI summary) The Trust has implemented several changes, including disseminating SIM meeting outcomes to care coordinators, documenting patient concerns on SystmOne, emphasizing risk mitigation in clinical supervision, and embedding a process for continuity of care during staff absences. A standing agenda item was added to daily meetings to address patient care during staff absence, with documented handover of responsibilities.
Kelly Stevens
All Responded
2024-0512 24 Sep 2024
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.
Action Taken (AI summary) WAHT has implemented a daily consultant review of medical outlier patients on surgical wards. The copy forward function on EPR was removed from 3 documents on 14th May 2024: Medical Clerking, Ward Round and Specialty Review, and then removed from all documents within the EPR system on 4th September 2024.
Margaret Maycroft
All Responded
2024-0509 20 Sep 2024
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that steps have been taken to ensure proper documentation and consideration of these measures.
Action Taken (AI summary) The Trust has enhanced staff training with falls simulation sessions, is implementing initiatives to improve multifactorial falls risk assessment, and has procured new lifting equipment with associated training. They also have mechanisms for ward managers to monitor falls interventions and audit documentation, which are reviewed in weekly forums, and falls are discussed weekly at various levels to identify support needs.
Alfred Sparrow
All Responded
2025-0405 6 Aug 2024
Cardinal Health
Care Home Health related deaths
Concerns summary (AI summary) Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his care plan; a false entry in Mr. Sparrow's notes gave rise to concern that staff might have been completing care note entries which did not reflect their actions.
Action Taken (AI summary) Cardinal Healthcare has already implemented several actions, including a manual reminder system for documentation, monitoring via a 'Resident of the Day' system, reflective practice sessions for staff, and a mentorship program for new staff. They are also planning to introduce a multi-layered review process for investigations, train managers, and strengthen collaboration with external bodies.
Peter Gregory
All Responded
2024-0430 2 Aug 2024
Civil Aviation Authority
Other related deaths Product related deaths
Concerns summary (AI summary) The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not regulate competition balloon flying, leaving critical safety aspects unaddressed despite known risks.
Action Planned (AI summary) The CAA is developing guidance on design, testing, and inspection of amateur-built balloons and will publish it by March 31, 2026. They are also working with the ballooning community to develop operational safety guidance on ascent/descent rates and event briefings, aiming for public consultation in late 2025. The CAA will publish safety guidance for balloon events to ensure risks are understood and managed, working with the British Balloon and Airship Club (BBAC). They will also continue their review of balloon flying regulation, with a supplemental report due by the end of March 2025.
Dominic Chapman
All Responded
2024-0309 6 Jun 2024
Department for Digital Culture, Media a… Ultra Events Ltd
Other related deaths
Concerns summary (AI summary) Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at charity white-collar boxing events.
Action Planned (AI summary) This document (Exhibit JL1) is a training workbook for Ultra Events boxing coaches, including sections on responsibilities, weight matching, learning expectations, and a scoring method. DCMS officials are preparing a targeted consultation of key stakeholders regarding possible amendments to the statutory guidance within the next six months to reduce the risks around white collar boxing. Ultra Events now requires medical providers to supply an event-specific risk assessment and Medical Plan. They also reference other changes implemented since April 2022 such as shorter round durations, more stringent standing 8 counts, and clearer wording in event instructions.