Avon
Coroner Area
Reports: 103
Earliest: Aug 2013
Latest: 18 Mar 2026
66% response rate (above 63% average).
Michael Hacker
Historic (No Identified Response)
2015-0179
8 May 2015
South Western Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns were raised regarding the ambulance service policy around the Mental Capacity Act, specifically regarding restraint or force if a patient lacks capacity but does not want to go to the hospital.
Sian Armstrong
Historic (No Identified Response)
2015-0019
21 Jan 2015
North Bristol NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
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 (AI 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
British Standards Institution
Department for Transport
Maritime and Coastguard Agency
Other related deaths
Concerns summary (AI 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
British National Formulary
UCB Pharma
Alcohol, drug and medication related deaths
Concerns summary (AI 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 (AI 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 (AI summary)
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Alan Stanfield Browning
Historic (No Identified Response)
2013-0315
26 Nov 2013
Somewhere House
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.
Garrett Joseph Franklin Elsey
Historic (No Identified Response)
2013-0316
22 Nov 2013
HSE's Waste and Recycling Sector Team
Other related deaths
Concerns summary (AI summary)
A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an alert system could improve awareness.