Avon

Coroner Area
Reports: 103 Earliest: Aug 2013 Latest: 18 Mar 2026

66% response rate (above 63% average).

103 results
Elizabeth Hutchins
All Responded
2023-0126 19 Apr 2023
Royal United Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating a severe failure in monitoring and timely clinical intervention.
Action Planned (AI summary) The Trust is re-purposing existing staff to operate as a Hospital at Night Team and has a business case for additional resources to support this, to be introduced from July 2023. The Outreach Nursing Team and Night Sisters will receive Acute Cardiac Syndrome (ACS) training from a Consultant Cardiologist, commencing within eight weeks.
Celia Marsh
All Responded
2022-0379 21 Nov 2022
British Hospitality British Retail Consortium British Society for Allergy and Clinica… +5 more
Other related deaths
Concerns summary (AI summary) The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk patients. There's also a lack of robust systems to capture anaphylaxis cases.
Noted (AI summary) The UK Health Security Agency states that responsibility for establishing systems related to food policy and anaphylaxis sits outside of their remit, and instead lies with the Food Standards Agency and the Health and Safety Executive. UKHospitality commits to carrying out a consultation with members on managing the risk of vegan dishes for people with hypersensitivity, and reflecting any recommendations in future updates to the Industry Guidance. The Food Standards Agency will focus on a smaller subset of priorities including Precautionary Allergen Labelling (PAL), improving information in the non-prepacked sector, and enabling a step-change in the knowledge, skills, and food safety culture of staff in the 'non-prepacked' sector through training. The Food and Drink Federation highlights existing guidance on allergen labelling, particularly regarding the differences between 'free-from' and vegan claims and will continue to support the work of the FSA. The British Retail Consortium supports members with label decisions but emphasizes company responsibility, noting challenges with 'free-from' and vegan definitions and the potential for unintended consequences with specific dietary statements. The British Society for Allergy and Clinical Immunology will consider holding an educational event on food avoidance in relation to adults with eczema and will address the need for improved recording and analysis of anaphylaxis fatalities. The Department of Health and Social Care acknowledges the recommendation to establish a robust system of capturing and recording cases of food-related anaphylaxis and notes that data regarding all anaphylaxis-related deaths in England and Wales are documented by the Office for National Statistics and the British Society for Allergy and Clinical Immunology also holds a register. The Royal College of Pathologists is updating its autopsy practice guidelines for suspected acute anaphylaxis to include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases.
Ami Mitchell
All Responded
2022-0356
Avon and Wiltshire Mental Health Trust
Suicide (from 2015)
Concerns summary (AI summary) Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation of care, or hospital admission.
Action Planned (AI summary) The Trust has completed a review of diagnostic processes and appointed a Consultant medical lead for diagnosis in South Gloucestershire, who will work to ensure all service users receive a diagnosis and formulation. This lead will also ensure care and treatment plans have clear escalation expectations, with progress to be audited in 3 and 6 months.
George Elliott
All Responded
2022-0309 4 Oct 2022
North Bristol NHS Trust
Other related deaths
Concerns summary (AI summary) The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and compromised patient safety.
Action Taken (AI summary) The Trust acknowledges shortcomings in the investigation report regarding Mr. Elliot's fall and states that the Falls Policy referenced has been replaced with an updated policy in December 2021. They are conducting a gap analysis using the PSIRF national guidance to improve investigation processes, and findings will be reported through relevant committees.
Gerwyn Rees
All Responded
2022-0248 8 Aug 2022
University Hospitals Bristol and Weston…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. This suggests a significant lack of learning and potential flaws in policy understanding or the policy itself.
Action Taken (AI summary) The Trust has reviewed its Enhanced Care Observation and Meaningful Activities Policy and the dementia, delirium and falls team has updated the falls prevention information leaflet as well as providing simulation based bespoke training to ward teams in the management of falls. A small central team of expert investigators will carry out patient safety incident investigations.
Donald Gore
Partially Responded
2022-0186 17 Jun 2022
Air Balloon Surgery Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent investigation into this incident was inadequate, lacked proper format, and was not disclosed.
Action Taken (AI summary) Air Balloon Surgery has conducted a Root Cause Analysis, created a new SEA policy and recording documentation, and shared the learning with the practice team. The surgery will share the learning from this incident to the wider Bristol Primary Care Community.
Susan Carling
All Responded
2022-0147 28 Apr 2022
Royal College of GPs, British Medical A…
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.
Noted (AI summary) The Department highlights resources such as Practitioner Health for healthcare workers and mentions national efforts to prevent suicide, including the cross-government strategy and investments in local prevention plans and bereavement services. They also reference the wellbeing support offer for healthcare staff and mental health hubs. The RCGP acknowledges the issue of suicide among health professionals and details the support and resources available, including Practitioner Health, The Doctors' Support Network, HHP Wales and the Sick Doctors Trust. They also collaborate with other stakeholders and are piloting a project supporting teams affected by sudden bereavement.
Reginald Weston
All Responded
2022-0008 11 Jan 2022
Blenheim House Care Home
Care Home Health related deaths
Concerns summary (AI summary) The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Action Taken (AI summary) The care home now requires that falls are recorded, and risk assessments are completed within 24 hours of any fall. Falls equipment audits have been taking place and more detailed accident and incident analysis has been included into the monthly accident audit. Pre-admission assessments are taking place in person when possible and The Berkley Care Group Training Manager is supporting Blenheim House with additional Falls Prevention Champion Training in Q2.
Maria Stancliffe-Cook
All Responded
2021-0235 8 Jul 2021
Avon and Wiltshire Mental Health Partne… Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.
Action Taken (AI summary) The Trust has implemented changes to improve understanding and application of risk assessment, including presentations from the Specialist Autism Team, an audit of the Triangle of Care, and an e-learning package on good practice when dealing with families and carers (due end of October 2021). DHSC highlights that the NHS has amended the post-discharge 7-day follow-up standard to 72 hours following discharge from inpatient mental health care, and the government is investing an additional £57 million in suicide prevention by 2023/24.
Anastasia Uglow
All Responded
2021-0216 24 May 2021
Department for Education
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
Action Planned (AI summary) The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP.
Jerome Peat
Historic (No Identified Response)
2021-0031 8 Feb 2021
Long Furlong Medical Centre
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Lesley Brass
Historic (No Identified Response)
2020-0113 28 May 2020
North Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.
Julie O’Connor
Partially Responded
2020-0129 30 Jan 2020
Department of Health and Social Care Royal College of Obstetricians and Gyna…
Community health care and emergency services related deaths
Concerns summary (AI summary) There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the need for further assessment over several months.
Action Planned (AI summary) The RCOG will be updating the article in The Obstetrician & Gynaecologist (TOG) entitled Nonmenstrual bleeding in women under 40 years of age and will work with the BGCS to review the training materials for suspected cervical cancer.
Alice Sloman
All Responded
2019-0442 16 Dec 2019
Torbay and South Devon NHS Trust University Hospitals Bristol
Child Death (from 2015) Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.
Action Planned (AI summary) Torbay and South Devon NHS Trust has discussed the case with relevant clinical teams and is implementing actions including: Paediatric clinicians learning about the Regional Genetic Service, Head of Regional Clinical Genetics Service attending a meeting with Paediatric clinical teams, twice yearly educational contact at clinical educational meetings, establishment of a regular advice point during/after the monthly clinics undertaken by the Regional Clinical Genetics Service in TSDFT. Bristol NHS Foundation Trust is working with Torbay and South Devon NHS Foundation Trust to finalise the Principles of Shared Care for Endocrine and has developed a patient information leaflet. It has been agreed that Service Levels Agreements will formalise the agreements in place with clear lines of accountability and responsibility.
Shaun Dewey
All Responded
2019-0398 19 Nov 2019
HM Prison and Probation Service
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.
Antonis Hannides
All Responded
2019-0382 8 Nov 2019
Spire Bristol Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.
Action Taken (AI summary) Spire Bristol Hospital has undertaken shared learning sessions with clinical staff to reiterate documentation procedures for patients who re-attend and asked the RMO involved to complete a reflection of the case for their appraisal. Spire Healthcare updated their Admission and Discharge Policy in January 2020.
Abdeslam Benelghazi
All Responded
2019-0337 10 Oct 2019
Department of Health and Social Care
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Action Planned (AI summary) The Department of Health and Social Care plans to publish a White Paper in early 2020 responding to the Independent Review of the Mental Health Act and will consult publicly on proposals to amend the Act.
Natasha Abrahart
All Responded
2019-0504 16 May 2019
Avon and Wiltshire NHS Mental Health Tr… Department of Health and Social Care Minister of Suicide Prevention +1 more
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Action Taken (AI summary) The trust issued a "Red Top Alert" to medical personnel regarding NICE guidelines for prescribing anti-depressants (CG90), including communication with primary care and documentation. It will also be discussed at various meetings across the trust to share learning. The University practice now books appointments to review patients starting SSRIs within one week, and clinicians ideally book the next appointment before the patient leaves, with a message to alert staff if the patient cancels. They've also requested funding for a Mental Health Nurse. The Department acknowledges the concerns and highlights existing guidelines and initiatives, including updated NICE guidelines on antidepressant prescription and various government-funded projects to improve student mental health support and reduce suicide risks.
Benjamin Murray
All Responded
2019-0155 16 May 2019
Bristol University Department for Education
Suicide (from 2015)
Concerns summary (AI summary) Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.
Action Planned (AI summary) The University has shared its mental health and wellbeing strategies with sector colleagues and provided support to other institutions where student deaths have occurred. From September 2019 the SPRG will oversee the undertaking of a serious incident review for every suicide or serious attempted suicide. UCAS is redesigning the question about disabilities, special needs, or mental health issues on the application form, with a roundtable discussion planned for July and implementation in 2020 for the 2021 entry. The UCAS Hub is also being explored to alleviate anxiety and signpost support services. The department will work with Universities UK to remind HE providers of the recommendation to carry out serious incident reviews. Public Health England is happy to work alongside partners to support the development of a serious incident framework.
Alexander Green
All Responded
2019-0117 1 Apr 2019
Royal United Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.
Action Taken (AI summary) The Trust has drafted a standard operating procedure for handovers, added an SBAR tool to the Paediatric proforma, developed a tool to safely exclude brain injury in intoxicated patients, and created a training tool with the South West Ambulance Service on "Confirmation Bias".
Marcie Tadman
Partially Responded
2019-0118 1 Apr 2019
Banes Clinical Commissioning Group Royal United Hospital, Bath
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No specific matters of concern were detailed in the provided text.
Action Planned (AI summary) The Trust shared a briefing paper with its commissioners detailing what would be required to deliver paediatric critical care, including an additional evening ward round, and is aiming to deliver twice daily consultant ward rounds and paediatric high dependency care by Winter 2019.
Evie Wright
All Responded
2019-0063 21 Feb 2019
North Somerset Council Persimmon Homes Severn Valley
Other related deaths
Concerns summary (AI summary) A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to stalled plans and unclear responsibility, despite acknowledged safety benefits.
Action Planned (AI summary) Persimmon Homes attended meetings with North Somerset District Council and agreed to attend a further meeting with Network Rail to explore an acceptable resolution, including a significant financial contribution for construction of the footbridge. North Somerset Council will meet with Persimmon Homes, seek Network Rail's engagement, and consider measures to improve crossing safety. By specific dates, they will seek Network Rail's confirmation of design requirements, agree to a draft project plan, and use best endeavors to determine any planning application.
Elizabeth Curtis
All Responded
2019-0018 11 Jan 2019
NHS Improvements
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.
Action Taken (AI summary) NHS Improvement has shared information with the Royal United Hospital Bath NHS Foundation Trust about a mobility score, and has provided support for assessing its impact. They are also undertaking activities related to medication safety for older people.
Christopher Seal
All Responded
2019-0013 10 Jan 2019
Avon and Wilshire Mental Health NHS Tru…
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.
Action Taken (AI summary) The Trust has already taken action to address the issues including emphasizing the need for staff to record explicit consent on information sharing forms and reviewing the Trust's consent to share information procedures. They have also clarified that the AWP switchboard can call 999 in an emergency and ensured that staff are aware of individualised communication options for service users.
Susan Longden
All Responded
2018-0394 18 Dec 2018
NHS Digital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Action Planned (AI summary) NHS Digital acknowledges that the question about a recent surgical procedure or operation is not specifically asked in a sub-section of their abdominal pain pathways and are reviewing how this might be included as part of a larger clinical review, which is due for completion later this year; and they do currently require that all users of NHS Pathways seek to talk directly with the patient where possible.