Cheshire
Coroner Area
Reports: 66
Earliest: Oct 2013
Latest: 12 Mar 2026
79% response rate (above 63% average).
Christine McDonald
Partially Responded CC
2024-0278
21 May 2024
HMP Styal
Ministry of Justice
Suicide (from 2015)
Concerns summary (AI summary)
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
Action Taken
(AI summary)
HMPPS launched a video in January 2024 demonstrating how staff should respond to a medical emergency, including the use of Code Blue and Code Red communications, which has been delivered to all new officers via foundation training. HMP Styal are committed to showing the video to all current operational members of staff by November 2024.
Oliver Barnett
All Responded
2024-0348
8 May 2024
Department of Health and Social Care
NHS England
Alcohol, drug and medication related deaths
Child Death (from 2015)
Concerns summary (AI summary)
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.
Noted
(AI summary)
NHS England expresses condolences and notes the concerns, but states that treatment for substance misuse is not within their remit. They highlight the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The Department acknowledges concerns about residential and detoxification facilities for young people, but states that inpatient detoxification is rare and should be managed by community services with hospital support. They highlight existing funding and support for local authorities to improve drug and alcohol treatment, and will keep service models under review.
Evie Davies
All Responded
2024-0241
2 May 2024
Cheshire and Wirral Partnership NHS Fou…
Spider Project Café 71
West Cheshire Clinical Commissioning Gr…
Suicide (from 2015)
Concerns summary (AI summary)
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Disputed
(AI summary)
The Trust clarifies the function of Cafe 71 and its liaison with the Trust and outlines how GPs are informed of contact with the crisis line, noting that the referral to Cafe 71 was made by the Trust's crisis line, not the GP. NHS Cheshire and Merseyside Integrated Care Board will work with CWP and GP colleagues to improve the timeliness and content of correspondence from the Crisis Line. The cafe has changed its referral forms to include consent for leaving voicemails and to gather more information about existing support for the individual being referred. Spider Project 1 disputes several points in the coroner's report, clarifying that the deceased never contacted Cafe 71 directly and that the referral from the Crisis Line gave no indication of immediate risk.
Nuliyati Businje
All Responded
2024-0441
23 Apr 2024
Department of Health and Social Care
National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.
Noted
(AI summary)
NICE acknowledges the concerns and explains its guideline on venous thromboembolism risk assessment, noting that it does not recommend a particular risk assessment tool and that clinicians should choose a tool that best fits the patient's clinical circumstances. The Department of Health and Social Care will work with NHS England to consider the VTE risk assessment tool, in light of the concerns raised.
Thomas Wakefield
All Responded
2024-0202
17 Apr 2024
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.
Noted
(AI summary)
NHS England states that the responsibility for clinical guidelines lies with NICE and the Royal Colleges, and highlights existing guidance from those bodies on AAA and acute pancreatitis. They note internal discussions and the sharing of learning from PFD reports nationally. NICE will review and consider changing the wording in section 1.2 of its guideline on pancreatitis regarding the confirmation of diagnosis by testing blood lipase or amylase levels. NICE has amended its guideline for pancreatitis (NG104) to clarify the interpretation of blood lipase or amylase levels in diagnosis.
Mary Jones
All Responded
2024-0159
21 Mar 2024
Amazon UK
Suicide (from 2015)
Concerns summary (AI summary)
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a previous coroner's intervention.
Noted
(AI summary)
Amazon has reviewed the book against its content guidelines and decided not to remove it from sale. They display a banner on the product detail page offering information on how to access free and confidential advice from the Samaritans.
Adrian Gallagher
All Responded
2024-0010
28 Dec 2023
Department of Health and Social Care
Suicide (from 2015)
Concerns summary (AI summary)
An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate age verification, posing a significant risk to vulnerable individuals.
Action Planned
(AI summary)
The National Crime Agency (NCA) is engaging with Ofcom to combat illegal suicide content online under the Online Safety Act. It also mentions the HMG Drugs Strategy, the Suicide Prevention Strategy and the Criminal Justice Bill, as well as the Department of Health and Social Care's work with Samaritans on the delivery of their online excellence programme. The Department for Science, Innovation and Technology outlines how the Online Safety Act will require tech companies to take responsibility for user safety and remove illegal content, including suicide and self-harm content. It details the duties of user-to-user services and search services, as well as enforcement powers for Ofcom. The Department of Health and Social Care is reviewing actions to reduce harm from suicide-related publications and collaborating with government departments, charities, and experts. They lead a cross-sector working group and support the Samaritan’s Online Excellence Programme.
Olivia Russell
All Responded
2023-0528
14 Dec 2023
Stretton Medical Centre
Suicide (from 2015)
Concerns summary (AI summary)
GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.
Action Planned
(AI summary)
The practice will audit care plans every 6 months, request GP review earlier than 2 weeks if needed, refer to CRISIS team for deterioration, have the Clinical pharmacist assist with medication review and arrange a follow-up appointment for any patients that DNA.
Glyn Ackerley
All Responded
2023-0478
27 Nov 2023
Department of Health and Social Care
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.
Noted
(AI summary)
NHS England explains the NHS Pathways system and its governance, noting that NHS Pathways is owned by DHSC and that all reports received are discussed by the Regulation 28 Working Group.
John Singleton
All Responded
2024-0126
16 Nov 2023
NHS England
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.
Action Planned
(AI summary)
NHS England will explore the functionality of the Health and Justice Information Service (HJIS) to flag medication non-compliance and work to facilitate roll out across the estate. In the interim, regional teams will be reminded of the requirement to monitor uncollected medicines.
Carl Fullalove
Partially Responded
2023-0408
25 Oct 2023
College of Policing
National Police Chiefs Council
Other related deaths
Concerns summary (AI summary)
Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.
Action Taken
(AI summary)
The College of Policing updated their First Aid Learning Programme (FALP) in April 2024 to include updated guidance on Acute Behavioural Disturbance (ABD), including de-escalation and communication strategies.
John Condron
Partially Responded
2023-0374
6 Oct 2023
Cheshire Police
National College of Policing
National Police Chief’s Council
Suicide (from 2015)
Concerns summary (AI summary)
There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.
Action Taken
(AI summary)
Cheshire Constabulary has reviewed its suspect policy and procedure, introduced in August 2023, and now specifies that when a decision is made not to take further action against a suspect, they must be updated at the earliest practicable opportunity or within 48 hours.
Emma Morrissey
All Responded
2023-0317
4 Sep 2023
Regenesis Health Travel Limited
Other related deaths
Concerns summary (AI summary)
Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, and embalming and medical reporting were inadequate.
Action Planned
(AI summary)
The Department of Health and Social Care is investigating global medical tourism, consulting with stakeholders, and planning a visit to Türkiye to discuss regulatory frameworks and patient protections. They will also lobby Turkish authorities on embalming standards and consider how to better communicate risks to those considering medical treatment abroad.
David Lyth
All Responded
2023-0233
7 Jul 2023
3D Trans, Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.
Action Taken
(AI summary)
HSE states that they will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles. HSE has conducted a further inspection of 3D Trans Ltd and is satisfied with the measures the company has put in place regarding training, monitoring, and supervision. 3D Trans has strengthened its training program to ensure that all drivers receive quarterly refresher training against the company's coupling and uncoupling procedure. This includes reviewing written procedures, watching a video, and completing a test.
Angela Craddock
All Responded
2023-0172
12 May 2023
HMP Altcourse, Ministry of Justice and …
Other related deaths
Concerns summary (AI summary)
An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, affecting risk assessment and recall procedures upon release.
Action Taken
(AI summary)
Cheshire HMCTS introduced Dedicated Domestic Abuse Courts (DDAs), where HMCTS, CPS, Cheshire Police, and Probation Services work together to improve information sharing. Cheshire Probation provides a dedicated Court Duty Officer in the DDA Court each day. HMP Altcourse has implemented a system where all documents are photocopied by Admissions, and the Public Protection Team collect them the following morning to implement relevant restrictions. Also, the Custody Department scans restraining orders and emails them to the OMU/Public Protection Unit.
Charles Rothwell
All Responded
2022-0312
5 Oct 2022
Department of Health and Social Care, N…
Community health care and emergency services related deaths
Concerns summary (AI summary)
Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.
Noted
(AI summary)
AACE acknowledges the coroner's concerns about ambulance response times and capacity and highlights that the issue has been flagged nationally, leading to a national demand and capacity modelling exercise led by NHSE.
Remi Koduah
Historic (No Identified Response)
2022-0085
18 Mar 2022
Mid Cheshire Hospitals NHS Foundation T…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.
Costel Stancu
All Responded
2019-0379
12 Nov 2019
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, and its safety implications were not reassessed during the 'smart motorway' conversion.
Action Planned
(AI summary)
National Highways will conduct a lighting assessment on the M6 between junctions 16 and 19, and complete the final Road Safety Audit (Stage 4) by Summer 2020.
Sam Spooner
All Responded
2019-0378
8 Nov 2019
Rope Green Medical Centre
Community health care and emergency services related deaths
Concerns summary (AI summary)
A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.
Noted
(AI summary)
BACP acknowledges the challenges faced by private counsellors regarding information sharing and will pass the report to their Professional Standards Department to consider strengthening current guidance. The counsellor, via their legal representation, outlines the existing procedures for information sharing, including obtaining client consent, and emphasises the limitations faced by private practitioners.
Hajra Sidat
All Responded
2019-0370
1 Nov 2019
Cheshire East Council
Cheshire East Highways Department
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.
Action Planned
(AI summary)
Cheshire East Highways has accepted the recommendation to replace the existing hazard centreline marking with a hatched hazard centreline on A34 Melrose Way, with works programmed to be carried out in March. • A road safety assessment report was prepared for A34 Melrose Way.
• The existing centre line marking was replaced with a hatched hazard centreline and red surfacing in March 2020 to discourage overtaking.
• These measures comply with national regulations and guidance.
Salma Sidat
All Responded
2019-0370-wp26883
1 Nov 2019
Cheshire East Council
Cheshire East Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.
Action Planned
(AI summary)
Cheshire East Highways has accepted the recommendation to replace the existing hazard centreline marking with a hatched hazard centreline on A34 Melrose Way, with works programmed to be carried out in March. Following a road safety assessment, Cheshire East Highways replaced the centre line marking on A34 Melrose Way with a hatched hazard centreline and red surfacing in March 2020, aiming to discourage overtaking.
Liyakat Sidat
All Responded
2019-0370-wp26882
1 Nov 2019
Cheshire East Council
Cheshire East Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The A34 bypass at Melrose Way Bend is dangerous due to the absence of a continuous white line, allowing unsafe overtaking in dark conditions and posing a risk to lives.
Action Planned
(AI summary)
• A road safety assessment report for the A34 Melrose Way was reviewed.
• The council accepted the report's recommendation to replace the existing hazard centreline marking with a hatched hazard centreline to narrow the carriageway visually.
• The works were programmed to be carried out in March. • A road safety assessment report for A34 Melrose Way was prepared.
• The existing centre line marking was replaced with a hatched hazard centreline and red surfacing.
• These works were completed in March 2020.
Mary Chapman
All Responded
2019-0360
8 Oct 2019
Nuffield Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Action Taken
(AI summary)
Nuffield Health has implemented a new national discharge policy, provided additional training, and improved communication protocols. They are extending consultant pharmacist support across all 31 locations and are standardising discharge processes.
Gladys Furnival
Historic (No Identified Response)
2019-0270
14 Aug 2019
Cheshire Constabulary
Cheshire Fire and Rescue
Department of Health and Social Care
+1 more
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.
William Hignett
Historic (No Identified Response)
2019-0138
26 Apr 2019
Cheshire West and Chester Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.