Worcestershire

Coroner Area
Reports: 82 Earliest: Sep 2013 Latest: 10 Mar 2026

73% response rate (above 62% average).

Response Status
Responded 60 No Response 2 Historic 12 Pending 4
AI Classification
Action Taken 90%
Action Planned 10%
Noted 0%
Disputed 0%
Based on 20 classified responses
Top Categories
Hospital Death (Clinical Procedure… (35) State Custody related deaths (16) Suicide (from 2015) (10) Mental Health related deaths (10) Care Home Health related deaths (9)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: +7 reports · +10pp response rate
vs national average: -1 reports · +11pp response rate
Clear 12 results
Peter Pearson
Historic (No Identified Response)
2022-0341 13 Sep 2022
Worcestershire County Council Care Quality Commission Corbett House Nursing Home
Care Home Health related deaths
Concerns summary A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.
Emily Caldicott
Historic (No Identified Response)
2022-0092 23 Mar 2022
Herefordshire and Worcestershire Health…
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.
Gareth Warburton
Historic (No Identified Response)
2019-0411 4 Dec 2019
HMP Hewell
State Custody related deaths
Concerns 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.
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 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.
Gareth Jones
Historic (No Identified Response)
2018-0340 5 Nov 2018
Worcestershire County Council
Road (Highways Safety) related deaths
Concerns 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.
Sidonio Teixeira
Historic (No Identified Response)
2017-0366 12 Dec 2017
HMP Long Lartin
State Custody related deaths
Concerns 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.
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 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.
James McGeown
Historic (No Identified Response)
2015-0506 22 Jul 2015
Worcestershire County Council
Road (Highways Safety) related deaths
Concerns summary An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.
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 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.
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.
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.