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
102 results
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,
Ami Mitchell
All Responded
2022-0356
Avon and Wiltshire Mental Health Trust
Suicide (from 2015)
Concerns summary Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation of care, or hospital admission.
Action taken summary Avon and Wiltshire Mental Health Partnership has reviewed diagnostic processes and appointed a Consultant medical lead for diagnosis in South Gloucestershire to ensure all service users receive a form