Avon

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

66% response rate (above 63% average).

Response Status
Responded 68 No Response 1 Historic 34
AI Classification
Action Taken 43%
Action Planned 41%
Noted 15%
Disputed 2%
Based on 101 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 · +1pp response rate
vs national average: +19 reports · +3pp response rate
103 results
Terence  Brooks
Historic (No Identified Response)
2016-0056 12 Feb 2016
Bath and North East Somerset Clinical C… Care Quality Commission Royal United Hospitals Bath NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.
Marilyn Anson
Historic (No Identified Response)
2016-0054 12 Feb 2016
North Somerset Clinical Commissioning G… North Somerset Community Partnership Weston Area Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.
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 (AI 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.
Action Planned (AI summary) A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and issue a vignette of Charlotte's care as a reflective training exercise, emphasizing multi-disciplinary working and care planning.
Scarlett Jukes
Partially Responded
2015-0449 27 Oct 2015
Foxhound Association Health and Safety Executive
Other related deaths
Concerns summary (AI summary) Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, posing a significant injury risk.
Action Planned (AI summary) The MFHA has initiated a full review of hats used for hunting and has begun gathering evidence; it plans to issue new Guidance Notes for Hunt Officials and Subscribers, aiming for approval at the MFHA AGM in June 2016.
George Hines
Historic (No Identified Response)
2015-0448 27 Oct 2015
Bristol City Council
Other related deaths
Concerns summary (AI summary) Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.
Kala Skinner
Historic (No Identified Response)
3 Sep 2015
Care Quality Commission South Western Ambulance Service NHS Fou…
Community health care and emergency services related deaths
Concerns summary (AI summary) Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and safeguarding patients.
Ben Hiscox
Historic (No Identified Response)
12 Aug 2015
The FA Group
Other related deaths
Concerns summary (AI summary) The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of injury or death, with no action taken by the referee.
Simon Reynolds
Historic (No Identified Response)
2015-0296 24 Jul 2015
Avon and Wiltshire Mental Health NHS Tr…
Mental Health related deaths
Concerns summary (AI summary) Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Masoud Ghaderi
Partially Responded
2015-0283 17 Jul 2015
Avon and Wiltshire Mental Health Partne… Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Action Planned (AI summary) The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will design a framework of staff responsibilities.
Alison Draper
Historic (No Identified Response)
2015-0205 29 May 2015
Avon and Wiltshire NHS Partnership Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.
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.
Kimberley Parsons
All Responded
2015-0077 4 Mar 2015
Avon and Wiltshire Mental Health Partne… Care Quality Commission
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) CQC carried out a comprehensive inspection of Avon and Wiltshire Partnership NHS Trust (AWP) in June 2014, leading to enforcement action and four warning notices. AWP addressed the warnings, including physical improvements to Hillview Lodge. A further comprehensive inspection will be undertaken before April 2016. The trust does not endorse harm minimisation strategies, but after a staff member mooted 'safe self-harm' they plan to issue an internal safety alert to all clinical staff to remind them of this position.
Christopher Taylor
Partially Responded
2015-0055 13 Feb 2015
Avon and Salisbury Constabulary Bath and North East Somerset Local Auth… Sainsburys Plc
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Sainsbury's met with local council and fire services, cleared vegetation to improve visibility and access, and maintains service level agreements. They also endorsed RoSPA's recommendation for user education and prioritize preventing falls into the river. Avon and Somerset Constabulary outlines changes to their communication services, including a new call scripting system with dynamic assessment capabilities to be adopted in April 2015. They have also established a consolidated Learning Board to drive forward lessons from events such as this.
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.
Peter Dorney
All Responded
2014-0504 17 Nov 2014
Southmead Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Action Taken (AI summary) North Bristol NHS Trust clarified that all new nurses receive mandatory Early Warning Score (EWS) training on induction and that 93% of all nurses have received EWS training. The directorate has reviewed which individuals have not received training, and measures are being put in place for those individuals to receive the training within the next 3 months.
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.
Robert Perkins
All Responded
2014-0195 28 Apr 2014
North Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did not raise concerns about this. The prescribed cervical collar was also not readily available despite the hospital being a regional neuroscience centre.
Action Taken (AI summary) The ED matron discussed communication failures with the nursing team. The hard collar safety alert and other materials related to cervical immobilisation will be redistributed to medical directors, CDs and included in medical staff inductions. A place for central storage of these devices is being looked for within the Emergency Zone and the accessibilily of rigid collars for the purposes of cervical immobllisation is being readdressed since the move into the new Brunel building.
Yasmin Richards
All Responded
2014-0193 28 Apr 2014
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Highways Agency has implemented local measures to highlight the nature of the road, including additional chevron signage, hazard warning signs, and high friction surfacing in strips. They are planning a peer review of the implemented scheme by the end of July 2014 and will gather data to ascertain its effectiveness.
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.
Felix Cembrowicz
All Responded
2013-0204 12 Dec 2013
Avon and Wiltshire Mental Health Partne…
Mental Health related deaths
Concerns summary (AI 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 (AI summary) Avon and Wiltshire NHS Trust will establish if re-referred patients have historic relapse management plans and an additional check should be undertaken in the RiO clinical records/documents to establish if they have been migrated across. This requirement is included in the current initial assessment/admission process and the Trust is updating supervision processes and information governance packages.
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.