Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0265, written 27 Apr 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Apr 2026 |
|---|---|
| Reference | 2026-0265 |
| Deceased | Michael Chadwick |
| Coroner | Nathanael Hartley |
| Coroner area | Nottingham and Nottinghamshire |
| Source | judiciary.uk record |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Clinical Director for Sherwood Forest Hospitals NHS Trust 2. Clinical Director for Nottingham University Hospitals NHS Trust 3. Practice Manager at Middleton Lodge Practice 1 CORONER I am Nathanael Hartley, assistant coroner for the coroner area of Nottingham and Nottinghamshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 22 December 2025 an inquest was opened into the death of Michael Chadwick, aged 47. The inquest concluded on 27 April 2026. I made a determination at inquest that he died as a result of injuries sustained in a road traffic collision. 4 CIRCUMSTANCES OF THE DEATH Mr Chadwick approached his GP at Middleton Lodge Practice (MLP) in 2022 with reports of breathlessness and headaches. He was later seen by a Consultant Neurosurgeon at Nottingham University Hospitals (NUH) and informed them of coughing, shortness of breath of exertion and having “blacked out” on a couple of occasions. Cough induced syncope episodes were reported to a Respiratory Consultant and a Consultant Cardiologist at Sherwood Forest Hospitals (SFH). He was seen at the Urgent Care Centre (UCC) at King’s Mill Hospital at SFH and reported the same. Mr Chadwick’s family accompanied him at appointments and do not recall him ever having been given advice about not driving and informing the DVLA of the change to his health. None of the letters sent to his GP confirming the outcome of these appointments make any reference to this advice being given. MLP was aware of the contents of a letter from SFH following his attendance at the UCC, which included the words “probale (sic) Cough Syncope”, and no guidance around driving was provided to Mr Chadwick by MLP. Mr Chadwick died following injuries sustained in a road traffic collision when the motorcycle he was driving left the road. An investigation revealed Mr Chadwick made no steering or other kind of input to the motorcycle when he left the road. I did not find, on balance, that a cough syncope caused the loss of control. 5 CORONER’S CONCERNS 1 During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. On the multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing. I am concerned that clinicians may fail to provide similar guidance to other patients, which may lead to episodes of syncope whilst driving, with potentially fatal consequences. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 June 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I will send a copy of my report to the Chief Coroner (upon receipt of your reply) and to the following Interested Persons: 1. Mr Chadwick’s family. I am under a duty to send the Chief Coroner a copy of your response and all interested persons who, in my opinion, should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 27 April 2026 Nathanael Hartley HM Assistant Coroner For Nottingham and Nottinghamshire 2
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Middleton Lodge Practice Church Circle, New Oilerton, Newark, Nottinghamshire, NG22 9SZ Friday, June 19, 2026 Mr Nathanael Hartley Assistant Coroner Nottingham City and Nottinghamshire Coroners Service Nottingham City House Council House Old Market Square Nottingham NG1 2DT Dear Mr Hartley Re: Michael Chadwick DOB 27.06.78 (deceased) Late of 13 Turner Lane, Boughton, Newark, Nottinghamshire, NG22 9HN Following on from your concerns outlined in your report for Mr Chadwick, we would like to take this opportunity on behalf of the Partnership at Middleton lodge Practice to offer our sincere condolences to the family of Mr Chadwick. We have continued to support his wife at this difficult time. We have performed a case review of his records and hospital correspondence specifically regarding potential missed opportunity of notification not to drive and the potential risk of future missed opportunity. Whilst I can see there has been mention on a number of occasions where Mr Chadwick had a sudden loss of consciousness collapse, later noting a diagnosis of cough syncope which is identified from your inquest, this would require advice to stop driving and DVLA notification, no mention of this advice is present in the GP records. I am unable to comment if this information was verbally given but not written, as both clinicians who saw Mr Chadwick during this time have since left our Practice, one emigrating. We have taken this opportunity to review and discuss Mr Chadwick's case at both senior and clinical level, where I presented a case presentation at a clinical meeting where it was felt that on balance the majority of clinicians present felt 1 that this was a complex case, had multiple speciality input but on balance would and should have resulted in advice regarding fitness to drive. As a Practice this has highlighted the need to refresh our knowledge of the DVLA standards and guidance for medical professionals. All clinicians were advised to keep this guidance as a bookmark for ease of access. We have also identified the importance of accurate documentation, if this advice is given verbally but not documented, even if fitness to drive has been consider but deemed safe, both relevant and need clear documentation. There is also the ability to quick code this advice via our clinical system, SystmOne. This also includes a quick guide and notification responsibilities of the patient and clinicians. One clinician reflected on a recent case of collapse where it was unclear if this advice was given, where they have since reviewed this case and contacted the patient for review, communicating the specialities involved that this advice has been given. Following from this I plan to run a system audit in 6months to audit the use of readcodes/identification. We continue to offer support to Mrs Chadwick and offer opportunity for further discussions. Yours sincerely Advanced Clinical Practitioner 2
Medical Director’s Office 3rd Floor, Trust Headquarters City Hospital Campus Hucknall Road Nottingham NG5 1PB Please ask for the Medical Director’s Executive Assistant 19 June 2026 Mr Nathanael Hartley HM Assistant Coroner for Nottingham City and Nottinghamshire HM Coroner’s Court The Council House, Market Square, Nottingham NG1 2DT Dear Mr Hartley Inquest: Michael Chadwick - Prevention of Future Death Report [PFDR] Response I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Report issued on 27th April 2026 following the Inquest into the sad death of Mr Michael Chadwick. The enclosed commentary document responds to each of the concerns raised relating to Nottingham University Hospitals NHS Trust. May I begin with offering my sincerest condolences to Mr Chadwick’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The actions taken in response to the learning from the inquest are summarised in the attached document. Oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight and the Committees of our Board will receive a progress report. I hope that this document provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust. Yours sincerely Medical Director and Responsible Officer GMC Number 4535218 Concerns identified through the PFDR The Trust responds to the concerns raised as follows: 1. On the multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing. The Coroner highlighted concern that clinicians may fail to provide similar guidance to other patients, which may lead to episodes of syncope whilst driving, with potentially fatal consequences. The Trust acknowledges the Coroner’s concerns regarding the lack of advice given to Mr Chadwick on his ability to drive and need to notify the DVLA. In response, the following actions are being taken: 1. Review of the NUH guidelines relating to Transient Loss of Consciousness The Trust’s current ‘Transient Loss of Consciousness’ guidance is approved until 2027 and includes guidance on providing patients with suspected transient loss of consciousness information on driving. The information provided links to the current DVLA guidance on assessing fitness to drive. This guideline was circulated on 15th June 2026 to all consultants across the Trust to ensure awareness. 2. Guidance from the Medical Director and DVLA circulated to all Consultants and Care Group Governance teams within the Trust to confirm the importance of providing this information to patients. A letter from the Medical Director has been circulated to all Consultants at the Trust (Appendix 1) to remind them of their professional duty to advise patients if their diagnosis may impact fitness to drive and to inform patients of their obligation to contact the DVLA in this regard. This guidance has also been included on the Trust’s KOHA system within which the Clinical Guidelines, Trust Policies and Standard Operating Procedures sit. Summary The actions outlined above are intended to address the concerns identified in the Prevention of Future Deaths Report regarding provision of driving advice to patients. I hope this response provides both you and the family reassurance of the Trust’s commitment to learning from this case and to strengthening the safety and quality of care for our patients. Appendix 1
Inquest touching the death of Michael Chadwick
Response of Sherwood Forest Hospitals NHS Foundation Trust to Regulation 28 report
to prevent future deaths
This is the organisational response from Sherwood Forest Hospitals NHS Foundation Trust
(SFH) to the Regulation 28: Report to Prevent Future Deaths issued by HM Assistant Coroner,
following the conclusion of the inquest touching the death of Mr Michael Chadwick.
We offer our condolences to Mr Chadwick’s family, and we hope our actions as a Trust
provides reassurance of our commitment to ensuring that we learn from this and prevent future
deaths.
During the course of the inquest there was one matter of concern raised, as follows;
1. On multiple occasions that Mr Chadwick was assessed, and his cough syncope
brought to the attention of the medical professionals, there was no advice given
to him to stop driving and to notify the DVLA of his cough syncope, either orally
or in writing.
The HM Assistant Coroner is concerned that clinicians may fail to provide similar guidance to
other patients, which may lead to episodes of syncope whilst driving, with potentially fatal
consequences.
An action plan has been formulated, and the Trust will continue to monitor the completion of
these actions by attaching evidence of their completion that will be securely stored on the
Trust’s datix incident system alongside the relevant action ID number to provide assurance of
their completion.
Patient Safety Alert – Fitness to Drive: Ask, Advise, Document
A Trust wide patient safety alert has been developed, regarding Fitness to Drive: Ask, Advise,
Document, this alert identifies that despite clinical contact, there was no documented evidence
that the patient was advised not to drive, or to notify the DVLA of a relevant change in health
status. The patient safety alert was signed off at Patient Safety Incident Response Group on
14/05/2026.
Communication to all Heads of Service and Clinical Governance Leads
Disseminate the DVLA guidance to colleagues via Clinical Governance meetings, reminding
clinicians that considering fitness to drive is part of routine clinical assessment where
conditions, symptoms or treatments may affect safe driving. As part of this communication
clinicians are required to familiarise themselves with the DVLA Assessing fitness to drive
guidance (2025). Added to all governance reports by 30th June 2026 and email sent to all
Heads of Service and Clinical Governance Leads in Medicine Division.
Add DVLA guidance to the Trust intranet.
The guidance will be added to the intranet, this can be searched with keywords such as
driving, drive, DVLA, or the full file name. This action is complete.
Add the DVLA guidance to be added to the learning area on EOLAS, as part of the
extended learning and resources.
The guidance will be added to the learning area.
The DVLA link regarding medical conditions to be added to Cardiology intranet page.
The DVLA link to be added to the Cardiology intranet page regarding medical conditions.
Actions added to Datix
Action
ID
Description
Planned action
Due date
Action
allocated
('To')
7154
Patient Safety Alert
for Fitness to Drive
7155
DVLA guidance to be
shared to all Heads
of Service and
Clinical Governance
Leads
7156
7157
7175
DVLA guidance to be
added to the Trust
intranet
Add the DVLA
guidance to the
learning area on
EOLAS, as part of the
extended learning
and resources
Available DVLA link
on the Cardiology
Specialist Intranet
Page
A Trust wide patient safety alert has been
developed, regarding Fitness to Drive: Ask,
Advise, Document, this alert identifies that
despite clinical contact, there was no
documented evidence that the patient was
advised not to drive, or to notify the DVLA
of a relevant change in health status. This
will be added to all governance reports.
Disseminate the DVLA guidance to
colleagues via Clinical Governance
meetings, reminding clinicians that
considering fitness to drive is part of routine
clinical assessment where conditions,
symptoms or treatments may affect safe
driving. As part of this communication
clinicians are required to familiarise
themselves with the DVLA Assessing fitness
to drive guidance (2025).
18/05/2026
Completed
30/06/2026
The guidance will be added to the intranet,
this can be searched with keywords such as
driving, drive, DVLA, or the full file name.
18/05/2026
Completed
The guidance will be added to the learning
area.
30/06/2026
The DVLA link to medical conditions
including syncope to be added to the
Cardiology intranet page.
31/05/2026
Signed off at Patient Safety Incident Review Group (PSIRG) 21/05/2026.
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