Bedfordshire and Luton

Coroner Area
Reports: 80 Earliest: Jan 2014 Latest: 19 Mar 2026

79% response rate (above 63% average).

Response Status
Responded 63 Historic 16
AI Classification
Action Taken 52%
Action Planned 37%
Noted 11%
Disputed 0%
Based on 75 classified responses
Top Categories
Hospital Death (Clinical Procedure… (25) Other related deaths (15) Alcohol, drug and medication relat… (12) Child Death (from 2015) (8) Suicide (from 2015) (8)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: +9 reports · +11pp response rate
vs national average: -4 reports · +16pp response rate
80 results
Leon Briggs
All Responded
2021-0330 4 Oct 2021
Association of Ambulance Chief Executiv… Bedfordshire Police EEAST +1 more
Emergency services related deaths (2019 onwards) Mental Health related deaths Police related deaths
Concerns summary (AI summary) The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Noted (AI summary) EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used.
Zahid Ahmed
All Responded
2021-0062 3 Mar 2021
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles experience mechanical defects and cannot pull into a safe place.
Action Taken (AI summary) Highways England notes the concerns and lists measures taken since the publication of a stocktake, including upgrading CCTV coverage, increasing the number of emergency areas, improving the signage, increasing education campaigns and the messaging that is shown to drivers.
Ibrahima Yahaia
All Responded
2020-0262 1 Dec 2020
Luton Borough Council
Community health care and emergency services related deaths Other related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.
Action Taken (AI summary) Luton Council is completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents, and have included the Health & Safety Executive in the process of reviewing safety measures. Any faded or missing signs on the Hatters Way section of the busway have been replaced, and the rest of the Busway is being reviewed for upgrading of signage.
Jerrelle McKenzie
Historic (No Identified Response)
2020-0144 17 Jul 2020
Department for Digital, Culture, Media …
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, via the internet, likely influenced by social media, leading to his overdose.
Joan Williams
Historic (No Identified Response)
2020-0128 16 Jun 2020
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary responsibility on the driver to inform the DVLA rather than mandating direct clinical referral.
Barrie Copeland
Historic (No Identified Response)
2020-0108 1 May 2020
TUI UK & Ireland, Wigmore House, Wigmor…
Other related deaths
Concerns summary (AI summary) Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those with poor eyesight, with no evidence of post-accident safety examination.
Sarah Young
Historic (No Identified Response)
2020-0119 10 Feb 2020
Bedford Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.
Helen Sheath
All Responded
2020-0107 27 Jan 2020
Association of Ambulance Chief Executiv… Emergency Call Prioritisation Advisory … National Association of Ambulance Medic…
Emergency services related deaths (2019 onwards) Mental Health related deaths Other related deaths
Concerns summary (AI summary) Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Noted (AI summary) The Association of Ambulance Chief Executives (AACE) outlines the triage process for 999 calls, the role of the Emergency Call Prioritisation Advisory Group (ECPAG), and references a letter sent to ambulance trusts in April 2019 from NHS England regarding clinical oversight for self-harm and suicidal patients. NASMeD previously encouraged all ambulance trusts to implement clinical review of these cases.
Russell Bowry
Historic (No Identified Response)
2019-0373 3 Nov 2019
The National Rigging Advisory Council (… PLASA Unusual Rigging Ltd
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or adequate safety features. This leads to routine unsafe practices, with riggers having minimal influence over their own fall protection.
Pamela Evans
All Responded
2019-0333 4 Oct 2019
Bedford Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Action Planned (AI summary) Bedford Hospital NHS Trust will ensure assessments and patient observations are carried out. The post falls protocols and level of escalation will be reviewed and there will be Shared learning and a reminder on contacting the critical care outreach team. Learning from this investigation will be shared using multi-channel communications.
Graham Saffery
All Responded
2019-0301 18 Sep 2019
N.I.C.E
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Action Taken (AI summary) The CCG has shared learning from the incident with other practices and the East of England NHS England, developed a SystmOne search to identify at-risk patients, briefed prescribing leads, and will continue to monitor a national dashboard for patients on specific medication combinations. They have also discussed the learning with chief pharmacists at local hospitals and ELFT.
Millie Creasy
Historic (No Identified Response)
2019-0293 6 Sep 2019
Luton & Dunstable NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.
David Bird
Historic (No Identified Response)
2019-0188 3 Jun 2019
Bedfordshire Police
Police related deaths
Concerns summary (AI summary) Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.
Matthew Jones
All Responded
2019-0187 3 Jun 2019
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was also overlooked in discharge planning.
Noted (AI summary) The Department of Health and Social Care acknowledges the concerns around coordinated, multi-agency working for patients on Community Treatment Orders, and refers to existing NICE and Mental Health Act guidance. No specific actions are described beyond signposting existing resources.
Mohammed Hussain
All Responded
2019-0122 13 Mar 2019
East London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, staff lacked insight into their actions.
Action Taken (AI summary) Further training on risk assessment and suicide prevention is being delivered to staff in Bedfordshire crisis services. A new Clinical Director for Crisis Pathway and Liaison has been appointed to review the crisis pathway, and the Trust is working with external experts to develop a new risk assessment tool for wider rollout; suicide prevention training is also being reviewed and refreshed.
Gwyneth Edwards
Historic (No Identified Response)
2019-0472 5 Feb 2019
Bedford Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Ryan Williams
Historic (No Identified Response)
2018-0341 6 Nov 2018
Network Rail
Railway related deaths
Concerns summary (AI summary) Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
Karl Brunner
Partially Responded
2018-0310 29 Oct 2018
ACPO Bedfordshire Police
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.
Noted (AI summary) Bedfordshire Police states that their officer training includes a module on managing choking detainees, and they issue officers with personal Pocket Face Masks. They believe their training complies with IOPC recommendations and College of Policing standards.
Stephen Lawson
All Responded
2018-0264 13 Aug 2018
Bedford Borough Council
Other related deaths
Concerns summary (AI summary) The car park has a history of suicides and easy access to the external barrier wall. There are also very few visible 'Samaritans' signs for pedestrians entering the car park.
Action Planned (AI summary) The council is assessing steel barriers and caging in car parks, to be completed within three months. It is also risk assessing car parks, reviewing emergency procedures and providing staff training, with both to be completed by 31 October 2018, and carrying out a signage audit, anticipated to be completed within two months.
Andrew Hanahoe
All Responded
2018-0184 19 Jun 2018
Network Rail
Suicide (from 2015)
Concerns summary (AI summary) A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.
Action Taken (AI summary) Network Rail has trained over 20,000 railway staff to intervene with people who may be at risk of suicide, funded and implemented a team of eight patrollers in the Thameslink area to conduct suicide prevention patrols, and engaged with the local authority to discuss community-based suicide prevention measures. They also highlight existing fencing and risk assessment protocols.
Michael Berry
Historic (No Identified Response)
2018-0157 22 May 2018
HM Prison Bedford
State Custody related deaths
Concerns summary (AI summary) A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Matthew Wilmot
All Responded
2018-0107 17 Apr 2018
B & D Civil Engineering Limited M & S Water Services
Other related deaths
Concerns summary (AI summary) Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.
Action Taken (AI summary) M&S Water Services has amended its team briefing to include a procedure for operatives to escalate concerns about "unique" locations to a supervisor, who will then decide on appropriate control measures. The briefing will be mandatory for new operatives and refreshed for existing operatives every six months. B & D Civil Engineering reports that M&S will amend its team briefing to emphasize assessing suitability of alternative pedestrian routes and escalating concerns to supervisors. The revised briefing will be mandatory for new operatives and refreshed for existing operatives every six months.
Mavis Reeves
All Responded
2018-0035 6 Feb 2018
First Port Retirement Property Services…
Care Home Health related deaths Other related deaths
Concerns summary (AI summary) The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.
Action Taken (AI summary) FirstPort has separated the master key in the key safe and stored it prominently. They investigated installing Safelink and an emergency telephone line at the entry gate, but concluded neither would add a further method of entry for emergency services.
Harminder Dhillon
All Responded
2017-0266 6 Nov 2017
Network Rail
Railway related deaths
Concerns summary (AI summary) The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.
Action Planned (AI summary) Network Rail is developing additional enhancements targeting accidental and deliberate misuse at Automatic Half Barrier Crossings (AHBCs). The Marston level crossing is scheduled to be replaced by a vehicular road bridge in 2019.
Mark Vagnoni
Partially Responded
2017-0286 11 Oct 2017
HMP Bedford HM Prison and Probation Service
State Custody related deaths
Concerns summary (AI summary) Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
Action Taken (AI summary) All staff at HMP Bedford were reminded of the importance of considering all available information prior to changing a prisoner's location, with monthly checks to ensure accurate record keeping. Staff will refresh their knowledge of NOMIS and a standardized induction program for new staff will be implemented by December 2017.