Avon
Coroner Area
Reports: 103
Earliest: Aug 2013
Latest: 18 Mar 2026
66% response rate (above 63% average).
Bertram Crawford
All Responded
2020-0130
17 Dec 2018
Suspension Bridge Trustees
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Trust plans to extend the height of the parapet anti-climb fencing over the span and build a walkway beneath each of the buttresses, requiring planning permission and compliance with legislation.
Annette Hill
All Responded
2024-0602
21 Sep 2018
Southmead Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Disputed
(AI summary)
North Bristol NHS Trust states that it is satisfied with implementing the Sepsis Six guidelines before the BTS COPD care bundle, as the former addresses an immediate risk to a patient's welfare. This is supported by the fact there is no national guidance that says that Sepsis Six should not apply to patients with COPD.
Henry Miller
All Responded
2018-0260
29 Aug 2018
FCO
Other related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The FCO has updated its travel advice for Colombia and Bolivia to include information on the risks of participating in spiritual cleansing ceremonies. This update was made on 31 August 2018.
Jacqueline Jordan
Historic (No Identified Response)
2018-0263
24 Aug 2018
Bristol City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing a significant risk to public safety.
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 (AI summary)
Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.
Action Taken
(AI summary)
The Trust has implemented an e-observations system on adult in-patient wards that automatically calculates NEWS, prompts observations, and escalates concerns. They are also providing training and education on "revised escalation" and will continue this as they switch to NEWS2 in October 2018.
Michalla Sweeting
Historic (No Identified Response)
2018-0165
21 May 2018
Bristol Community Health
Community health care and emergency services related deaths
State Custody related deaths
Concerns summary (AI summary)
Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Yazin Elhjaje
Historic (No Identified Response)
2024-0601
26 Apr 2018
University Hospitals Bristol NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.
John Wherlock
Historic (No Identified Response)
2018-0089
28 Mar 2018
Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.
Sandra Miller
Historic (No Identified Response)
2018-0037
25 Jan 2018
Milestones Trust
Care Home Health related deaths
Concerns summary (AI summary)
Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Rebecca Romero
Historic (No Identified Response)
2017-0369
13 Dec 2017
Avon & Wiltshire Mental Health Partners…
Dorset Healthcare University NHS Trust
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.
Irene Baker
All Responded
2017-0363
11 Dec 2017
Rosewood Lodge Nursing Home
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Rosewood Lodge has overhauled care plans, improved the management team structure, provided further staff training, and implemented a new computerised care plan software system and CCTV in communal areas. They also use sensor mats for residents at high risk of falls.
Shaun Berryman
All Responded
2017-0424
27 Nov 2017
Wells Road Surgery
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The surgery is ensuring all medically relevant conversations occur in the consulting room for appropriate examination and privacy. 'Walk-in' patients are now added to the on-call triage list as a visual reminder to write relevant information in patient records.
Jonathan Shaw
Historic (No Identified Response)
2017-0418
23 Nov 2017
Highways Department, Bat and North East…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve highway safety at a dangerous bend were not implemented.
Terence Davies
Historic (No Identified Response)
2017-0419
20 Nov 2017
Banes Highways
Banes Park and Services
Canal Trust Bath
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.
Callum Smith
Partially Responded
2017-0185
7 Jun 2017
Avon and Wiltshire Mental Health NHS Tr…
Bristol Community Health
HMP Bristol
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.
Action Planned
(AI summary)
Following the inquest, all healthcare staff will revisit the Prison Service Instruction (PSI) through Suicide and Self Harm (SASH) training and local training/meetings to ensure staff are fully aware of their obligations when adhering to PSI 64/2011.
Rayan Ahmed
Historic (No Identified Response)
2017-0148
3 May 2017
North Bristol NHS Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.
David Birtwistle
Historic (No Identified Response)
2017-0139
18 Apr 2017
Brisdoc
NHS, University Hospital Bristol NHS Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
Isabel Gentry
Historic (No Identified Response)
2017-0111
6 Apr 2017
Committee of Vaccination and Immunisati…
Department of Health and Social Care
John Ratcliffe Hospital
+1 more
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.
Margaret Jones
Historic (No Identified Response)
2017-0053
22 Feb 2017
Avon and Somerset Constabulary
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road signage, and better carriageway markings to enhance driver safety.
Martyn Watkins
Partially Responded
2016-0409
14 Nov 2016
Avon and Wiltshire Mental Health Partne…
Care Quality Commission
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Action Taken
(AI summary)
The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract.
John Jones
Historic (No Identified Response)
2016-0327
5 Sep 2016
Avon and Wiltshire Mental Health Partne…
Mental Health related deaths
Concerns summary (AI summary)
A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Oliver Ford
All Responded
2016-0306
15 Aug 2016
Avon and Wiltshire NHS Trust
Mental Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians are required to document on RIO a full rationale for decision making.
Rohan Fitzsimons
Partially Responded
2016-0288
7 Aug 2016
Avon and Wiltshire Mental Health Partne…
Bristol Clinical Commissioning Group
Care Quality Commission
Community health care and emergency services related deaths
Concerns summary (AI summary)
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Action Taken
(AI summary)
The Trust has reviewed and simplified its joint protocol for the Management of Missing Persons and Absent Without Leave, consulting with clinicians and police. A standard template to record relevant information has been developed and is being disseminated, and regular audits will be undertaken to ensure compliance.
Stephanie Marks
Historic (No Identified Response)
2016-0233
20 Jun 2016
Clevedon Medical Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon by general practitioners.
Joseph Sarkozi
Partially Responded
2016-0055
12 Feb 2016
Avon Fire and Rescue Services
Chief Fire & Rescue Adviser
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Avon Fire & Rescue will include the incident scenario in training packages for operational crews, notify personnel via the "Fire Alert" system, amend the Domestic and Residential Fires risk card, and distribute the Fire Alert via CFOA to raise awareness.