Cambridgeshire and Peterborough

Coroner Area
Reports: 49 Earliest: Oct 2013 Latest: 29 Dec 2025

71% response rate (above 62% average).

Response Status
Responded 35 Historic 14
AI Classification
Action Taken 48%
Action Planned 21%
Noted 31%
Disputed 0%
Based on 29 classified responses
Top Categories
Hospital Death (Clinical Procedure… (26) Child Death (from 2015) (13) Community health care and emergenc… (8) Mental Health related deaths (8) Suicide (from 2015) (8)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: -21 reports · +5pp response rate
vs national average: -34 reports · +9pp response rate
49 results
Daniel France
Historic (No Identified Response)
2022-0047 16 Feb 2022
Cambridgeshire and Peterborough NHS Fou…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Suicide (from 2015)
Concerns summary Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like the Gender Identity Clinic, leaving a critical gap in support between urgent and non-urgent mental health interventions.
Ethel Beaumont
Historic (No Identified Response)
2021-0377 9 Nov 2021
Department of Health and Social Care Cambridgeshire and Peterborough Clinica… North West Anglia NHS Foundation Trust
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital request.
James Nowshadi
All Responded
2021-0260 29 Jul 2021
Royal College of Psychiatrists Public Health England Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future fatalities.
Jonathan Kingsman
All Responded
2021-0238 13 Jul 2021
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.
Christine Gould
All Responded
2021-0185 28 May 2021
Network Rail British Transport Police
Child Death (from 2015) Police related deaths Railway related deaths Suicide (from 2015)
Concerns summary Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.
Samantha Gould
All Responded
2021-0186 28 May 2021
Company Chemists’ Association General Pharmaceutical Council Royal Pharmaceutical Society +1 more
Alcohol, drug and medication related deaths Child Death (from 2015) Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Suicide (from 2015)
Concerns summary There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Lola Sheldrake
Historic (No Identified Response)
2021-0156 17 May 2021
National Institute for Clinical Excelle…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.
Alvin Black
Historic (No Identified Response)
2021-0130 30 Apr 2021
Minister of State for Prisons and Proba…
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.
Sean Kay
All Responded
2021-0124 28 Apr 2021
NHS Norfolk Waveney Clinical Commissioning Group
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.
Averil Hart
All Responded
2021-0058 3 Mar 2021
Academy of Medical Medical Royal Colleg… General Medical Council NHS England +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.
Myla Deviren
Historic (No Identified Response)
2019-0311 24 Sep 2019
Herts Urgent care Limited NHS 111 Public Health England
Child Death (from 2015) Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.
Rosa King
All Responded
2019-0239 12 Jul 2019
Local Government Association Food and Rural Affairs Health and Safety Executive +4 more
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear national guidance on firearm requirements for zoos, increasing risk to human life.
Peter Saint
Partially Responded
2017-0404 17 Nov 2017
NHS England North West Anglia NHS Trust Royal College of Anaesthetists +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since 2011.
Sam Crick
All Responded
2017-0457 25 Aug 2017
Barking, Havering and Redbridge Univers… Care Quality Commission NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Richard Davies
Partially Responded
2017-0325 24 Jul 2017
Bedfordshire Police Constabulary National Police Council
Police related deaths
Concerns summary A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.
Edward Mallen
Historic (No Identified Response)
2016-0254 7 Sep 2016
Cambridge and Peterborough NHS Trust NHS England Cambridgeshire and Peterborough Clinica… +1 more
Community health care and emergency services related deaths Suicide (from 2015)
Concerns summary A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
Peter Lawrence
Historic (No Identified Response)
2016-0314 30 Aug 2016
National Offender Management Service
State Custody related deaths
Concerns summary The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
Kevin Hoey
All Responded
2015-0101 17 Mar 2015
East of England Ambulance Service NHS T…
Community health care and emergency services related deaths
Concerns summary The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community or transfer them to hospital.
Anne Sandever
All Responded
2014-0393 4 Sep 2014
Hinchingbrooke Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.
Stephen Bedford
Historic (No Identified Response)
2014-0159 9 Apr 2014
East of England Ambulance NHS Trust
Community health care and emergency services related deaths
Concerns summary Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Malcolm Potter
Historic (No Identified Response)
2014-0082 27 Feb 2014
Network Rail
Railway related deaths
Concerns summary The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a busy commuter line.
Christopher James Morgan
Historic (No Identified Response)
2013-0272 22 Nov 2013
Cambridgeshire and Peterborough NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
James Edward Mansfield
Historic (No Identified Response)
2013-0288 10 Oct 2013
Nuffield Road Medical Centre
Community health care and emergency services related deaths
Concerns summary Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Samantha Gould and Christine Gould
All Responded
2021-0184
Alcohol, drug and medication related deaths Child Death (from 2015) Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Police related deaths Railway related deaths Suicide (from 2015)
Concerns summary Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action taken summary The Trust acknowledges the ongoing need for a 24/7 home treatment service, progressing this at an ICS level and submitting a business case for funding. It will remind doctors of …