Avon

Coroner Area
Reports: 102 Earliest: Aug 2013 Latest: 22 Oct 2025

67% response rate (above 62% average).

Response Status
Responded 68 Historic 30
AI Classification
Action Taken 62%
Action Planned 21%
Noted 14%
Disputed 3%
Based on 29 classified responses
Top Categories
Hospital Death (Clinical Procedure… (43) Other related deaths (17) Community health care and emergenc… (15) Mental Health related deaths (13) Child Death (from 2015) (11)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: +21 reports · +3pp response rate
vs national average: +19 reports · +5pp response rate
Clear 51 results
Benjamin Murray
All Responded
2019-0155 16 May 2019
Bristol University Department for Education
Suicide (from 2015)
Concerns 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.
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 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.
Alexander Green
All Responded
2019-0117 1 Apr 2019
Royal United Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Evie Wright
All Responded
2019-0063 21 Feb 2019
North Somerset Council Persimmon Homes Severn Valley
Other related deaths
Concerns 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.
Elizabeth Curtis
All Responded
2019-0018 11 Jan 2019
NHS Improvements
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.
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 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.
Susan Longden
All Responded
2018-0394 18 Dec 2018
NHS Digital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Bertram Crawford
All Responded
2020-0130 17 Dec 2018
Suspension Bridge Trustees
Other related deaths
Concerns summary A dangerous cluster of student deaths from the bridge, including three this year and four in two years, raises serious concerns about safety at this historical site.
Annette Hill
All Responded
2024-0602 21 Sep 2018
Southmead Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.
Henry Miller
All Responded
2018-0260 29 Aug 2018
FCO
Other related deaths
Concerns summary The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage tribal ceremonies, ensuring they make informed safety decisions.
Graham Fox
All Responded
2018-0192 22 Jun 2018
University Hospitals Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.
Irene Baker
All Responded
2017-0363 11 Dec 2017
Rosewood Lodge Nursing Home
Care Home Health related deaths
Concerns summary The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.
Shaun Berryman
All Responded
2017-0424 27 Nov 2017
Wells Road Surgery
Community health care and emergency services related deaths
Concerns summary A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.
Oliver Ford
All Responded
2016-0306 15 Aug 2016
Avon and Wiltshire NHS Trust
Mental Health related deaths
Concerns summary The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Joseph Sarkozi
All Responded
2016-0055 12 Feb 2016
Avon Fire and Rescue Services
Community health care and emergency services related deaths
Concerns summary Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Charlotte Bevan and Zaani Malbrouck
All Responded
2015-0418 27 Oct 2015
Avon and Wiltshire Mental Health NHS Tr…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Kimberley Parsons
All Responded
2015-0077 4 Mar 2015
Avon and Wiltshire Mental Health Partne… Care Quality Commission
Suicide (from 2015)
Concerns summary Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training failures.
Christopher Taylor
All Responded
2015-0055 13 Feb 2015
Avon and Salisbury Constabulary Sainsburys Plc
Community health care and emergency services related deaths
Concerns summary The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life buoy stations.
Peter Dorney
All Responded
2014-0504 17 Nov 2014
Southmead Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Yasmin Richards
All Responded
2014-0193 28 Apr 2014
Highways Agency
Road (Highways Safety) related deaths
Concerns summary The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.
Robert Perkins
All Responded
2014-0195 28 Apr 2014
North Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, and insufficient staff awareness created a high risk of serious injury.
Felix Cembrowicz
All Responded
2013-0204 12 Dec 2013
Avon and Wiltshire Mental Health Partne…
Mental Health related deaths
Concerns summary The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Action taken summary The Trust has updated its initial assessment/admission process to require staff to check for historic relapse management plans and other key documents (CPA, risk assessments) from previous electronic
Jared William McDowall
All Responded
2013-0245 27 Sep 2013
University Hospitals Bristol NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Action taken summary University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Rose Jean Coles
All Responded
2013-0246 27 Sep 2013
University Hospitals Bristol NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Action taken summary University Hospitals Bristol has developed a composite action plan to address concerns regarding communication between neonatal and cardiac units for premature babies, and the cut-off weight guideline
Ann Margaret Spearing
All Responded
2013-0217 20 Aug 2013
REDACTED
Community health care and emergency services related deaths
Concerns summary Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.
Action taken summary Bristol CCG is re-procuring specialist mental health and learning disability services for more flexible, person-centred care. They have also implemented an enhanced advice and guidance scheme for GPs,