Coroners were not satisfied enough learning had taken place to prevent future deaths in similar circumstances
Queen’s Medical Centre(Image: Joseph Raynor/ Reach PLC)
Nine deaths could have been prevented if Nottinghamshire’s hospital trusts didn’t make colossal mistakes, coroners concluded last year.
Nottinghamshire’s coroners have shared their concerns about the county’s hospital trusts on nine occasions in 2025, calling for action to be taken to address the issues.
The concerns regard Nottingham University Hospitals NHS Trust, Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire Healthcare NHS Foundation Trust and Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust.
These were highlighted in Prevention of Future Deaths Reports (PFDR), which are issued by coroners under the Coroners and Justice Act 2009 to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.
Nottingham University Hospitals NHS Trust (NUH)
NUH received a PFDR from coroner Nathanael Hartley after David Jones, aged 65, died on the same day he was discharged from Queen’s Medical Centre (QMC), which the trust runs.
Mr Jones died on April 5, 2024, from an undiagnosed aortic dissection, a condition that, after being left undiagnosed, has led to a number of inquests involving NUH, coroner Hartley said.
Mr Hartley explained in his report that a lack of further clinical assessment from the hospital staff “probably, more than minimally, caused or contributed to David’s death”.
He added that learning which “may make a difference to future patients presenting with atypical aortic dissections” has not been identified by the trust or passed on to staff members in the emergency department and beyond despite multiple similar inquests having taken place in the past.
Mr Hartley said: “I am concerned about recurrence for other patients who present atypically, and that the patients who experience similar significant developments whilst in hospital may remain unreviewed by those with the appropriate skill and seniority, and a risk of death from undiagnosed aortic dissections may follow.”
Sherwood Forest Hospitals NHS Foundation Trust (SFH)
In November last year, Dr Elizabeth Didcock, assistant coroner for Nottinghamshire warned of serious issues at King’s Mill Hospital, run by SFH.
This came after a 34-year-old man – Connor Nelson – died at the hospital on November 30, 2024, after staff at the Emergency Assessment Unit significantly delayed resuscitating him during a cardiac arrest on November 10, 2024.
Dr Didcock concluded that Mr Nelson’s death was “contributed to by neglect” and that his resuscitation was “sub-optimal”, with staff delaying the administration of necessary shock by nine minutes.
The coroner said: “There was a significant delay in providing a necessary defibrillator shock during the arrest, which made a more than minimal, negligible or trivial contribution to his death.”
In a Prevention of Future Deaths report released on December 3, Dr Didcock said she was concerned about the lack of evidence of any improvement in the ability of Emergency Assessment Unit staff to respond effectively to a cardiac arrest.
Another concern was regarding the lack of understanding by medical staff of the importance of identifying prolonged QTc syndrome in patients, as was the case with Mr Nelson, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the King’s Mill cardiology team.
Sophie enjoyed the theatre and cooking(Image: Leisa Towle)
Sophie Towle died aged 22 on May 27, 2024, from a pulmonary thromboembolus at King’s Mill Hospital whilst she was detained under section 3 of the Mental Health Act 1983.
She had been receiving treatment there after a self-harming incident on May 12 left her unable to walk, which eventually caused a blood clot to form in her leg and move to her lung, causing the pulmonary embolism.
Coroner Alexandra Pountney raised concerns about the policy and procedures around the management of insertion of foreign objects for SFH.
An inquest jury also listed the information sharing between King’s Mill and Sherwood Oaks Hospital, where Sophie was receiving care for her mental health, as a probable contribution to her death.
Nottinghamshire Healthcare NHS Foundation Trust (NHFT)
The same inquest jury also concluded in October 2025 a litany of failures by NHFT led to Sophie Towle‘s death.
Sophie, from Mapperley, had been in and out of mental health facilities since 2021.
When she was last sectioned in late 2023, she was situated at a mental health facility in Doncaster due to a lack of beds in Nottinghamshire.
She found the experience much better than when she’d stayed at other hospitals run by NHFT in the past and believed she was making progress with her mental health.
But on April 24, 2024, she was transferred back to Sherwood Oaks, a hospital run by NHFT where Sophie had been receiving care.
When she got there, there was no body mapping done, no wound care done, no assessment care plan made, no weight management care plan made, no reassessment of her blood clot risk and an inconsistent care plan with regards to her physical observations.
Two weeks later, on May 12, Sophie self-harmed by sticking the plastic ink container of a biro pen into an open wound on her left leg – while on 24/7 observations with a healthcare assistant sitting in the doorway watching her.
The jury also found that Sophie’s care was ‘substandard’ due to staffing levels and a lack of staff experience, with a reliance on bank staff who didn’t necessarily know Sophie.
There was no continuity of care and a lack of policy awareness and compliance.
Due to the damning string of errors, coroner Alexandra Pountney also warned action should be taken by staff at NHFT to prevent future deaths in circumstances similar to Sophie’s.
Gunaratnam Kannan died aged 63 at King’s Mill Hospital after taking an overdose of tablets on March 19, 2025, a day after telling paramedics to leave his home.
A 999 call was first made on March 18 and Mr Kannan told paramedics that he had taken the tablets to end his life, refusing to go to hospital and asking the paramedics to leave.
Mr Kannan’s GP spoke to the patient over the phone and found Mr Kannan had the mental capacity to make his decision not to go to hospital.
A further assessment could have then taken place under the Mental Health Act to determine whether a person needs to be taken to hospital without their consent.
Coroner Sarah Wood raised concerns surround disagreement over how that further assessment should have taken place.
An inquest heard that the NHFT’s crisis team told paramedics they would not attend Mr Kannan’s home until the following day, adding that his GP should make a referral for a Mental Health Act assessment.
Yet the GP told paramedics that the Mental Health Act assessment was a matter for the crisis team and paramedics ended up having to leave Mr Kannan’s home on March 18, telling his daughter to call for an ambulance if her father deteriorated.
The East Midlands Ambulance Service (EMAS) then received a further 999 call on March 19 from Mr Kannan’s son-in-law.
Coroner Wood explained in her PFD report, which she sent to NHFT, East Midlands Ambulance Service and the Royal College of General Practitioners that “there is a clear lack of understanding between these service providers as to what actions should be taken and by who”.
At the beginning of 2025, a joint inquest took place in front of coroner Laurinda Bower to explore the circumstances in which three HMP Lowdham Grange prisoners died in just as many weeks.
David Richards died at HMP Lowdham Grange in March 2023(Image: Essex Police)
Anthony Binfield, 30, David Richards, 42, and Rolandas Karbauskas, 49, all died at Lowdham Grange after being found with ligatures around their necks in March 2023.
At the time of the three deaths, NHFT was the healthcare provider at HMP Lowdham Grange.
The deaths came just six weeks after the management of the prison changed hands from Serco to Sodexo, believed to be the first private-to-private company transfer.
The facility was taken over permanently by the Government just over a year later due to deteriorating safety, prisoner conditions and staffing levels.
The jury inquest, which began in November 2024 and concluded in February 2025, revealed “various shortcomings in culture and system processes with regards to both prison and healthcare”.
Rolandas Karbauskas was one of the three prisoners to die(Image: Lincolnshire Police)
The jury also found that, during the transfer period between Serco and Sodexo, there was confusion about which regime was to be followed and numerous departments were left feeling overwhelmed.
Other issues mentioned include inadequate assessments, sharing of risk-pertinent information and a shortage of experienced health care staff.
Coroner Bower expressed her concerns in a PFD report sent to Lord Timpson, minister for prisons, NHS England, Mark Whittaker, managing director for justice and immigration services at Serco, Tony Simpson, justice director at Sodexo, and Ifti Majid, chief executive at NHFT.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Emily Hewerdine had Crohn’s disease and required a subtotal colectomy and end ileostomy on April 19, 2024.
Following her discharge, Ms Hewerdine developed complications which led to her being admitted to Bassetlaw Hospital, run by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, in Worksop on April 27.
During her admission, she developed an ileus with sub-acute small bowel obstruction which was not recognised by medical staff.
Ms Hewerdine also developed an acute kidney injury due to dehydration, which was also not recognised.
The lack of recognition led to a lack of necessary investigations, coroner Elizabeth Didcock concluded in July 2025.
Ms Hewerdine further deteriorated due to her unidentified conditions and dehydration and died on May 6, 2024.
Dr Didcock explained that, had necessary treatment for the bowel blockage and evolving dehydration been provided as it should have been, on balance Ms Hewerdine would not have died when she did.
She called for the trust to make improvements in order to avoid further deaths in similar circumstances.
Marina Raisbeck died aged 82 at Doncaster Royal Infirmary (DRI) after a delayed transfer from Bassetlaw Hospital on November 7, 2023.
The elderly woman had several significant chronic medical problems that had caused her to be housebound.
Ms Raisbeck was taken to Bassetlaw Hospital after an abscess on her buttock became infected but staff soon found that she had developed sepsis.
Yet, as it was a Saturday, Bassetlaw Hospital was unable to perform surgery on Ms Raisbeck, meaning she required to be transferred to DRI.
The transfer was delayed, however, which means the surgery at DRI also had to be pushed back until the next morning.
While treatment was given appropriately and medical staff carried out the right procedures for Ms Raisbeck, coroner Didcock ruled that Ms Raisbeck was not a subject of discussion between the emergency department of Bassetlaw Hospital and the surgical team at DRI.
This ultimately meant that Ms Raisbeck was not prioritised for an urgent transfer, which led to her death, as priorisation systems were not in place for high-risk patients.
Dr Didcock has warned more deaths could take place if this wasn’t addressed.
