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
Clear 31 results
Fallon Adams
All Responded
2025-0647 29 Dec 2025
Northamptonshire Healthcare Foundation …
Alcohol, drug and medication related deaths
Concerns summary There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause fatal over-sedation.
Action taken summary The Trust has reminded prescribing clinicians of expectations regarding assessment and management of sedative burden, re-emphasised documentation standards for clinical observations, and introduced a
Benedict Blythe
All Responded
2025-0595 25 Nov 2025
Cambridgeshire Constabulary Royal College of Pathologists
Child Death (from 2015) Other related deaths
Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.
Action taken summary The Royal College of Pathologists notes that existing autopsy guidelines for suspected acute anaphylaxis (2018) provide specific guidance on sampling blood and stomach contents. They will query the in
Judith Hughes
All Responded
2025-0563 6 Nov 2025
Chief Medical Officer for North West An…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Action taken summary The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing …
Christian Hobbs
All Responded
2025-0176 7 Apr 2025
Royal College of Emergency Medicine Royal College of Radiology Faculty of Intensive Care Medicine +5 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Action taken summary The Northamptonshire Safeguarding Children Partnership cannot comment on the specific historical CDOP review due to missing records, but assures that all CDOP forms and communications are now properly
Amelia Ridout
All Responded
2025-0077 7 Feb 2025
British Society for Haematology (BSH) NHS England National Institute for Health and Care …
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.
Action taken summary NHS England states that developing clinical guidelines or a database for BMA and trephine biopsy does not sit within their remit. However, they commit to investigating evidence regarding training/supe
Patricia Curtis
All Responded
2024-0669 4 Dec 2024
NHS England Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new clinical settings.
Action taken summary NHS England states that individual Trusts are responsible for discharge policies but refers to existing national guidance and role-based action cards. It notes that the specific Trust (Royal Papworth)
Declan Morrison
All Responded
2024-0570 23 Oct 2024
Department of Health and Social Care Cambridgeshire and Peterborough Integra… NHS England
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his death.
Action taken summary NHS England detailed that £124 million was made available in 2024/25 for local areas to invest in community mental health services for people with learning disabilities and autistic people. They …
Richard Roe
All Responded
2024-0693 22 Oct 2024
NORTH WEST ANGLIA NHS FOUNDATION TRUST
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until a long-term IT solution is implemented.
Action taken summary The Trust is implementing an interim measure to produce monthly reports of unviewed routine CT scans from the current radiology system, which will be followed up with requesting clinicians. They …
Rachel Gibson
All Responded
2024-0476 30 Aug 2024
Royal College of Anaesthetists
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Jennifer Bunyan and Marion Bunyan
All Responded
2024-0406 26 Jul 2024
Department for Transport Cambridgeshire County Council
Road (Highways Safety) related deaths
Concerns summary An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of delayed safety barrier implementation despite previous fatalities, created severe dangers.
Action taken summary The Department for Transport clarifies that highways maintenance funding allocation is for local authorities to manage based on local priorities and that the DfT does not intend to enforce cluster …
Terrence Taylor
All Responded
2024-0336 21 Jun 2024
Care Quality Commission Department of Health and Social Care British Standards Institute
Care Home Health related deaths Product related deaths
Concerns summary Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.
Action taken summary BSI's expert committee for windows, doors, and rooflights has agreed to review the relevant standard (BS 8213-1) to consider incorporating different requirements for residential care homes and address
Colin McCallum
All Responded
2024-0279 21 May 2024
REDACTED
Road (Highways Safety) related deaths
Concerns summary Unmanaged risk of flooding and standing water on a specific road stretch has led to multiple incidents of vehicles losing control, posing a continued risk of future deaths.
Kellie Sutton
All Responded
2024-0239 30 Apr 2024
Hertfordshire Constabulary
Suicide (from 2015)
Concerns summary Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.
Brian Chapman
All Responded
2024-0164 24 Jan 2024
Department for Transport
Road (Highways Safety) related deaths
Concerns summary Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable risk of death or injury to passengers in collisions.
Joanne Constable
All Responded
2023-0536 20 Dec 2023
Cambridgeshire County Council
Road (Highways Safety) related deaths
Concerns summary The local authority lacks systems to record, track, and confirm action on highway complaints and defects, meaning reported hazards may not be remedied and posing a clear risk of future fatal road incidents.
Gregor Lynn
All Responded
2023-0537 20 Dec 2023
NHS England Cambridgeshire Peterborough Integrated … Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A cost barrier in private healthcare discourages patients from crucial histological analysis of lesions, unlike NHS treatment where it's included, risking delayed cancer detection for those not meeting NHS referral criteria.
Chantelle Reed
All Responded
2023-0349Deceased 21 Sep 2023
Royal College of Radiologists NHS England Royal College of Emergency Medicine
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Louis Thorold
All Responded
2023-0311 18 Aug 2023
Department for Transport Cambridge County Council
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue driving.
Amelia Barbosa
All Responded
2023-0167 19 May 2023
North West Anglia NHS Foundation Trust
Child Death (from 2015)
Concerns summary Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and blood transfusions for neonatal resuscitation.
Milan Hamza
All Responded
2023-0142 27 Apr 2023
Cambridgeshire County Council
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road incidents.
Karen Starling and Anne Martinez
All Responded
2022-0368 14 Nov 2022
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.
James Nowshadi
All Responded
2021-0260 29 Jul 2021
Department of Health and Social Care Royal College of Psychiatrists Public Health England
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
British Transport Police Network Rail
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.