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
Clear 34 results
Clinton Fear
Historic (No Identified Response)
2023-0286 29 Jun 2023
UK Health Security Agency
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.
Christopher Evans
Historic (No Identified Response)
2023-0132 24 Apr 2023
Care Quality Commission Department of Health and Social Care Supported Independence Limited
Other related deaths
Concerns summary (AI summary) A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, as no regulatory body assesses or requires thermostatic controls, unlike other health and social care settings.
Jerome Peat
Historic (No Identified Response)
2021-0031 8 Feb 2021
Long Furlong Medical Centre
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Lesley Brass
Historic (No Identified Response)
2020-0113 28 May 2020
North Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Concerns summary (AI summary) The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.
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.
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.
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.
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.
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.
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.
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.
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.
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.