Avon
Coroner Area
Reports: 102
Earliest: Aug 2013
Latest: 22 Oct 2025
67% response rate (above 62% average).
Elsie Plumb
Historic (No Identified Response)
2014-0455
21 Oct 2014
Royal College of Obstetricians and Gyna…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
Gerardo Tonogbanua
Historic (No Identified Response)
2014-0245
27 May 2014
Department for Transport
Maritime and Coastguard Agency
British Standards Institution
Other related deaths
Concerns summary
A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also failed, exacerbated by vague guidance on safety device performance.
Dafydd Watts
Historic (No Identified Response)
2014-0194
29 Apr 2014
UCB Pharma
British National Formulary
Alcohol, drug and medication related deaths
Concerns summary
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
Scarlett Sinclair
Historic (No Identified Response)
2014-0059
3 Feb 2014
Oxford University Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.
Chloe Grace Flavell
Historic (No Identified Response)
2014-0003
6 Jan 2014
Weston Area Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.