Worcestershire

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

77% response rate (above 63% average).

Response Status
Responded 64 No Response 4 Historic 15
AI Classification
Action Taken 66%
Action Planned 27%
Noted 7%
Disputed 0%
Based on 85 classified responses
Top Categories
Hospital Death (Clinical Procedure… (36) State Custody related deaths (16) Suicide (from 2015) (10) Mental Health related deaths (9) Care Home Health related deaths (9)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: +9 reports · +13pp response rate
vs national average: -1 reports · +14pp response rate
83 results
Rachel Johnston
Partially Responded
2021-0090 26 Mar 2021
Care Quality Commission Field Fisher Solicitors Holmleigh Care Homes Ltd +1 more
Care Home Health related deaths
Concerns summary (AI summary) The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Action Taken (AI summary) Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do not work and are reported, and implemented a Professional Boundaries policy requiring staff to comply with standards of conduct.
Roy Campbell
All Responded
2020-0059 9 Mar 2020
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Action Planned (AI summary) The Trust is implementing environmental risk assessment forms on wards, with completion covered in new staff inductions and existing staff supervision sessions. While a business case for an electronic visitor system is awaiting approval, additional manual checks are in place, and pre-signing of forms is prohibited.
Jason Devoti
All Responded
2020-0017 21 Jan 2020
West Midlands Police
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards) Mental Health related deaths
Concerns summary (AI summary) West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.
Action Taken (AI summary) West Midlands Police details steps taken to improve emergency call response, including involving the Force Incident Manager during busy periods, implementing a "Log Closure Doctrine," and reducing the number of logs held by each dispatcher. They are also working on a record of missing person logs managed and overseen by supervisors until resolved.
Gareth Warburton
Historic (No Identified Response)
2019-0411 4 Dec 2019
HMP Hewell
State Custody related deaths
Concerns summary (AI summary) Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
David Kirsch
All Responded
2019-0362 30 Oct 2019
HMP Long Lartin
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.
Action Taken (AI summary) HMPPS has revised training for ACCT case managers, emphasising consistency, Caremap completion, and information sharing, with guidance sent to existing case managers at Long Lartin and training for all Band 4 and 5 staff by June 2020. They have also reviewed the ACCT process and devised a new version of the form and associated guidance, piloted in ten establishments in 2019.
Kevin McDonald
Historic (No Identified Response)
2019-0156 16 May 2019
Worcestershire Acute Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.
Kelvin Speakman
Partially Responded
2019-0074 27 Feb 2019
HMP Hewell HM Prison Service
State Custody related deaths
Concerns summary (AI summary) The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.
Action Planned (AI summary) HMPPS will deliver coaching sessions to ACCT case managers at HMP Hewell, emphasizing information sharing and accurate recording. A updated ACCT case management system is being piloted and will be rolled out nationally in early 2020.
Gareth Jones
Historic (No Identified Response)
2018-0340 5 Nov 2018
Worcestershire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This location has a history of fatal road traffic incidents.
Stephen Taylor
All Responded
1 Nov 2018
University Hospital Coventry and Warwic…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
1 response from Stephen Taylor
Bethany Shipsey
All Responded
2018-0049 15 Feb 2018
Department for Health
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its possession or supply illegal.
Action Taken (AI summary) The Department of Health acknowledges concerns about DNP and highlights existing actions including FSA's '#dnpkills' campaign, monitoring by the National Poisons Information Service, and warnings issued to GPs and emergency departments; they will continue to consider further actions.
Gail Bannister
All Responded
2018-0039 9 Feb 2018
Worcester Health and care Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.
Action Planned (AI summary) Worcestershire Health and Care NHS Trust is installing a new telecommunications system with call forwarding at Studdart Kennedy House, with a survey completed and a capital bid to be submitted; interim measures include a mobile telephone for staff to contact the site/duty worker.
Sidonio Teixeira
Historic (No Identified Response)
2017-0366 12 Dec 2017
HMP Long Lartin
State Custody related deaths
Concerns summary (AI summary) The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.
Michael Giles
All Responded
2017-0309 30 Oct 2017
Worcestershire Acute Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.
Action Planned (AI summary) The Trust has undertaken an audit of record keeping, is developing a clinical records keeping video, and is providing human factors training; it will continue to audit patients unexpectedly brought to intensive care.
Emma Timbrell
Historic (No Identified Response)
2016-0426 30 Nov 2016
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.
Matthew Sargent
All Responded
2016-0138 7 Apr 2016
Government Legal Department Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Noted (AI summary) Care UK notes the concerns raised but states that the role and responsibilities of Personal Officers fall within the remit of the Prison Service. They note that PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of prisoner's ACCT status ACCT alerts and risk assessments. Following concerns regarding the Personal Officer scheme, the prison will ensure that all staff are reminded of the policy. In response to concerns about historical information, a process has been put in place to ensure that staff have access to historical information where this information is available.
Jonathan Lander
All Responded
2016-0114 18 Mar 2016
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.
Action Taken (AI summary) The Trust has implemented a Substance Misuse Information Sharing Protocol with Swanswell Worcestershire Recovery Partnership. Action Plans from Root Cause Analyses are now uploaded to an Embedded Lessons Database, monitored by the Governance Team.
Stewart Akins
All Responded
2016-0091 3 Mar 2016
West Mercia Constabulary
Police related deaths
Concerns summary (AI summary) Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Action Taken (AI summary) West Mercia Police revised its practice so all Prisoner Escort Forms are signed as accurate by the custody sergeant, who has overall responsibility for ensuring risks are correctly documented and communicated. Mandatory training for custody sergeants includes highlighting known risks to the OIC upon consideration for MG7 remand application.
Bryan Catanach
Historic (No Identified Response)
1 Dec 2015
Royal Orthopaedic Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Stephen Adams
Historic (No Identified Response)
30 Nov 2015
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Wayne O’Neill
All Responded
2015-0444 26 Oct 2015
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.
Action Taken (AI summary) All patients prescribed anti-psychotic medication will receive a routine annual ECG as part of their care; the Lead Pharmacist will sample audit this by 31 January 2016. Training will be provided to the Nursing team regarding medicines that should indicate a referral for an ECG, and the issue of anti-psychotic medication and extended QT intervals will be included in HMP Long Lartin GP supervision session and the Mental Health MDT meeting.
Liam Smith
Partially Responded
2015-0382 18 Sep 2015
Governor HMP Hewell Worcestershire Health and Care Trust
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Action Taken (AI summary) HM Prison and Probation Service has reiterated the professional obligation of clinical staff to review relevant parts of prisoner's notes and has changed practices relating to high risk drug users by implementing a follow up ledger to SystmOne within three working days of the detoxification programme ending.
James McGeown
Historic (No Identified Response)
2015-0506 22 Jul 2015
Worcestershire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.
Noel Jones
All Responded
2015-0155 22 Apr 2015
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
Action Taken (AI summary) The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer.
Leonardus Vries
All Responded
2015-0088 9 Mar 2015
Royal Orthopaedic Hospital NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.
Action Taken (AI summary) The Royal Orthopaedic Hospital reviewed controls around controlled and non-controlled drugs, updated Standard Operating Procedures for Controlled Drugs, conducted audits and found compliance with required standards.
Francoise Snape
Historic (No Identified Response)
2015-0054 13 Feb 2015
Worcestershire Acute Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.