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
James Colton
Partially Responded
2015-0021 20 Jan 2015
HMP Long Lartin Healthcare Worcestershire Health and Care Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also inadequate pain management, poor continuity of care, and communication failures.
Action Taken (AI summary) The trust held study sessions reviewing the case notes of Mr. Colton, increased the consultant psychiatrist's sessions at HMP Long Lartin, appointed a clinical director for offender healthcare, and formalised a new process for clinical supervision through the South Worcestershire Federation.
Eve Cullen
All Responded
2015-0002 8 Jan 2015
Worcestershire Health and Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.
Action Taken (AI summary) Worcestershire Health Care NHS Trust conducted a serious review and acknowledges differences in urgent referral processes across the county. As a result, it is working with North CCGs to introduce a standardised system county-wide and towards performance measures for all referral categories with defined timescales.
Seweryn Glowinski
Historic (No Identified Response)
2014-0446 15 Oct 2014
HMP Long Larkin
State Custody related deaths
Concerns summary (AI summary) Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Caroline Carter Crowther
Historic (No Identified Response)
2014-0418 24 Sep 2014
West Midlands Ambulance Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.
Dana Baker
All Responded
2014-0242 29 May 2014
Worcestershire Safeguarding Children’s …
Other related deaths
Concerns summary (AI summary) Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Noted (AI summary) The WSCB acknowledges the concerns but states that national practice is followed and questions if the report should have been directed to the Department for Education. The guidance in place at the time of the EW Serious Case Review (SCR) was undertaken is outlined, that which is now in place and WSCB's response to this is set out.
Sean Seabourne
Historic (No Identified Response)
2013-0374 17 Dec 2013
Worcestershire Health and Care NHS Trust
Mental Health related deaths
Concerns summary (AI summary) Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Henry McQuoid
Historic (No Identified Response)
2013-0348 6 Nov 2013
Moundsley Hall Nursing Home
Community health care and emergency services related deaths
Concerns summary (AI summary) Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.
Reggie John
Partially Responded
2013-0202 16 Sep 2013
HMP Bristol HMP Hewell Worcestershire Health and Care NHS Trust
State Custody related deaths
Concerns summary (AI summary) Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Action Taken (AI summary) The trust reiterated expectations regarding ACCT documents for prisoners arriving at HMP Hewell, and reviewed Prison Service Instruction 64/2011 to identify and address areas of non-compliance. HMP Bristol introduced a system to contact receiving establishments about prisoners on open ACCTs, and HMP Hewell issued a notice reminding staff to report information indicating a change in a prisoner's potential for self-harm. Operational Orders reinforce multi-disciplinary ACCT reviews.