Worcestershire
Coroner Area
Reports: 82
Earliest: Sep 2013
Latest: 10 Mar 2026
73% response rate (above 62% average).
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
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.
Seweryn Glowinski
Historic (No Identified Response)
2014-0446
15 Oct 2014
HMP Long Larkin
State Custody related deaths
Concerns 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
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
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Sean Seabourne
Historic (No Identified Response)
2013-0374
17 Dec 2013
Worcestershire Health and Care NHS Trust
Mental Health related deaths
Concerns 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
Unknown
2013-0348
6 Nov 2013
Community health care and emergency services related deaths
Concerns 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 Hewell
HMP Bristol
Worcestershire Health and Care NHS Trust
State Custody related deaths
Concerns 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 summary
Following the inquest, the Lead for Offender Health set out clear expectations to all healthcare staff at HMP Hewell regarding ACCT documents for arriving prisoners, ensuring they are available to …