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
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 (AI 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 Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
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 (AI 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 Planned (AI summary) University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Ann Margaret Spearing
All Responded
2013-0217 20 Aug 2013
Chair
Community health care and emergency services related deaths
Concerns summary (AI 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 (AI summary) Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services and has piloted an enhanced advice and guidance support scheme to GPs.