Cheshire
Coroner Area
Reports: 65
Earliest: Oct 2013
Latest: 12 Mar 2026
74% response rate (above 62% average).
Tania Jarman
Response Pending
2026-0143
12 Mar 2026
Department of Health and Social Care
Suicide (from 2015)
Concerns summary
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Ruairi Stewart
Response Pending
2026-0138
10 Mar 2026
Alternative Futures Group
Alcohol, drug and medication related deaths
Concerns summary
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, and a deficient post-incident investigation.
William Webb
Response Pending
2026-0117
26 Feb 2026
Canal & River Trust
Other related deaths
Concerns summary
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.
Alan Crabtree
Response Pending
2026-0103
20 Feb 2026
Greater Manchester Medicines Management…
Alcohol, drug and medication related deaths
Concerns summary
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
Pippa Gillibrand
Response Pending
2026-0042
27 Jan 2026
NHS England
Department of Health and Social Care
National Institution for health and car…
Child Death (from 2015)
Concerns summary
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.
Alan Mitchell
All Responded
2025-0577
10 Nov 2025
Optum
Alcohol, drug and medication related deaths
Concerns summary
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.
Action taken summary
Optum disputes the factual accuracy of the concern, clarifying that their EMIS Web system does not automatically remove repeat prescriptions after 12 months without GP notification. They explain the s
Charlotte Tetley
All Responded
2025-0465
14 Sep 2025
Chief Constable of Cheshire Police
Suicide (from 2015)
Concerns summary
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, increasing risk of death.
Action taken summary
Cheshire Constabulary explains their 'Right Care, Right Person' policy and states that the hospital's subsequent enquiries led to them determining no further concerns, thereby withdrawing their reques
Charlotte Tetley
All Responded
2025-0466
14 Sep 2025
Cheshire and Wirral Partnership NHS Tru…
Suicide (from 2015)
Concerns summary
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Action taken summary
Cheshire and Wirral Partnership NHS Foundation Trust has implemented system changes including direct documentation of Clinical Prioritisation Meeting outcomes, establishing a Patient Flow Meeting, dev
Margaret Douglas
Partially Responded
2025-0309
18 Jun 2025
1st Care 4U
Minster Care Group
Holcroft Grange
Care Home Health related deaths
Concerns summary
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Action taken summary
Minster Care Group has implemented new procedures to assess agency workers' English language competency and integrated agency worker induction policy into monthly audits. They have also enhanced hando
Simon Hockenhull
All Responded
2025-0295
12 Jun 2025
Royal Pharmaceutical Society
Alcohol, drug and medication related deaths
Concerns summary
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Action taken summary
The Royal Pharmaceutical Society explained the complexities around medication pack sizes and dispensing regulations, stating that pharmacists use professional judgment and can issue emergency supplies
Edward Wilson
All Responded
2025-0281
5 Jun 2025
North West Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
Action taken summary
The North West Ambulance Service concluded, following a specialist review, that the treatment afforded to Mr Wilson adhered wholly to national guidelines and there were no contraindications for salbut
Joseph Powell
All Responded
2025-0234
17 May 2025
Royal College of General Practitioners …
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Action taken summary
The RCGP will highlight this case to its Mental Health Special Interest Group to promote safety planning in suicide prevention and consider GP booking of follow-up appointments as part of …
Sarah Boyle
All Responded
2025-0211
2 May 2025
HMPPS
Ministry of Justice
State Custody related deaths
Suicide (from 2015)
Concerns summary
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.
Action taken summary
HMPPS has provided national safety team support to HMP Styal, delivering a local safety summit and upskilling staff on self-harm and suicide risk awareness. The Governor and healthcare provider will …
Victor Knowles
Partially Responded
2025-0002
2 Jan 2025
Henning Hall Nursing Home
Springcare Care Homes Ltd
Care Home Health related deaths
Concerns summary
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Action taken summary
Springcare Care Homes Ltd disputes the necessity of the report, stating their existing internal investigation policies are comprehensive and appropriate. They assert that no further changes are requir
Alexandra Roberts
All Responded
2025-0006
2 Jan 2025
NHS England
Alcohol, drug and medication related deaths
Concerns summary
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Action taken summary
NHS England plans to recommend that annual medication reviews consider patients' mental health and wellbeing when prescribing high-risk medicines like insulin. They will also review prescription quant
Charles Daniels
All Responded
2024-0575
4 Sep 2024
Stepping Hill Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Action taken summary
NHS Stockport disputes that Mr Daniel's condition was significantly deteriorated at discharge or that nurses failed to alert doctors, stating he was medically assessed as fit for discharge. They apolo
Nathan Scantlebury
Partially Responded
2024-0417
23 Jul 2024
Department for Education
Department of Health and Social Care
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.
Action taken summary
NHS England has introduced NHS-Led Provider Collaboratives and invested funding to improve the availability of local inpatient care for children and young people, resulting in fewer inappropriate out-
Tony Williams
All Responded
2024-0385
18 Jul 2024
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary
HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging bales on slopes, particularly concerning widthways loading and centre of gravity risks.
Action taken summary
The HSE disputes the need for additional images or supporting material in their guidance, stating their current goal-setting advice is sufficient for safe bale handling. They note that DVSA guidance …
Peter Dolan
All Responded
2024-0370
11 Jul 2024
Boat Safety Scheme
Other related deaths
Concerns summary
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation and burns.
Action taken summary
The Boat Safety Scheme will conduct a public consultation by the end of this year to research evidence for introducing a mandatory requirement for smoke alarms on all boats. They …
Andrew Story
All Responded
2024-0357
3 Jul 2024
Foreign, Commonwealth & Development Off…
Other related deaths
Concerns summary
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming conditions, despite high public usage.
Action taken summary
The FCDO transmitted the Regulation 28 report to the British Consulate in Crete for onward transmission to the relevant Greek authorities, but stated they could not guarantee a response from …
Michael Harrison
All Responded
2024-0321
14 Jun 2024
ALLMI
Accident at Work and Health and Safety related deaths
Concerns summary
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of accidental activation.
Action taken summary
ALLMI disputes the Coroner's reference to 'HIAB design' as a factual inaccuracy, explaining that existing loader crane designs meet safety standards and that suggested modifications (audible sound, tw
Graham Faulkner
All Responded
2024-0317
13 Jun 2024
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and implement preventative measures.
Action taken summary
The HSE explains why no investigation was triggered by the initial RIDDOR report, stating it did not meet their Incident Selection Criteria (ISC). They largely dispute the need to specifically …
David Scott
All Responded
2024-0284
26 May 2024
Warrington Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.
Christine McDonald
Partially Responded
2024-0278
21 May 2024
Ministry of Justice
HMP Styal
Suicide (from 2015)
Concerns summary
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
Emma Morris
All Responded
2024-0282
21 May 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to wait in A&E.