Cheshire

Coroner Area
Reports: 66 Earliest: Oct 2013 Latest: 12 Mar 2026

79% response rate (above 63% average).

Response Status
Responded 52 No Response 2 Historic 11
AI Classification
Action Taken 31%
Action Planned 35%
Noted 28%
Disputed 5%
Based on 74 classified responses
Top Categories
Suicide (from 2015) (15) Hospital Death (Clinical Procedure… (14) Road (Highways Safety) related dea… (8) Alcohol, drug and medication relat… (7) Other related deaths (6)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: -54 reports · +16pp response rate
vs national average: -18 reports · +16pp response rate
66 results
Mark Parry
All Responded
2019-0094 19 Mar 2019
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack essential guidance on risks and safety strategies.
Action Planned (AI summary) HSE plans to issue a safety alert identifying control measures for air suspension systems on all vehicle types, aiming to finalise it by August 2019. Longer term, HSE will amend PM85 and review HSG261 to address control measures in relation to ejection.
Katharine Dowling
All Responded
2019-0089 14 Mar 2019
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited ASD-appropriate environments and inadequate, unmonitored staff training increase patient risk in psychiatric wards.
Action Planned (AI summary) NHS England is planning to address consistency of care for patients with ASD and co-existing mental health diagnoses by developing clear guidance for clinicians and ward staff, expanding ASD support services, increasing alternative forms of crisis provision, and developing a Core Capabilities Framework for Supporting Autistic People.
Maureen Colclough
All Responded
2017-0318 27 Jul 2017
Care Agency Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary) Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.
Action Taken (AI summary) CQC has raised the provider's failure to notify them of the death, conducted an inspection, found all staff received basic life support training in August/September 2017 with additional training in late September/early October, and is taking substantive enforcement action requiring an action plan to improve care. Unique Care Services has notified all employees and revised performance appraisals to include recognizing emergency situations, ensured new starters receive relevant information, and mandated extra Emergency First Aid training for all employees.
David Holman
All Responded
2017-0018 30 Jan 2017
Cheshire East Council, Highway Departme…
Road (Highways Safety) related deaths
Concerns summary (AI summary) A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an unsafe environment for cyclists.
Action Planned (AI summary) Cheshire East Council has programmed works to remove and relocate a road sign situated in the footway and re-kerb a length of the road to provide a higher consistent kerb height. The Road Safety Team will also conduct a complete Safety Assessment of the carriageway regarding the provision of a cycleway.
Frederick Chisnall
All Responded
2017-0017 30 Jan 2017
Halton Clinical Commissioning Group St Helens Clinical Commissioning Group
Care Home Health related deaths
Concerns summary (AI summary) Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Action Taken (AI summary) Following a safeguarding investigation, Reflex Agency provided further training to its staff, and disciplinary action was taken against a nurse by St Mary's Nursing Home, who also assured they would no longer use Reflex Agency for non-registered staff. The Team Manager for St Helens Contracts and Quality Monitoring service liaised with the agencies for assurance of actions taken.
Thomas Coyne
Historic (No Identified Response)
2017-0207 19 Jan 2017
Northern Rail
Railway related deaths
Concerns summary (AI summary) Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access to the tracks, posing a serious safety risk.
David Moran
All Responded
2017-0008 6 Jan 2017
5 Boroughs NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.
Action Taken (AI summary) The Trust has implemented a telephone system for the Assessment Team, piloted in Warrington in December 2016 and due Trust-wide by April 2017. All information relating to patients and their referrals must be documented within the electronic patient recording system (RiO), and a senior clinical member of staff reviews all referrals daily.
Charles Woodward
Historic (No Identified Response)
2016-0449 16 Dec 2016
Cancer Governance Board Mid Cheshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
Janet Millar
Historic (No Identified Response)
2016-0444 15 Dec 2016
Bowmere Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking policy.
Brian Gerrard
Historic (No Identified Response)
2016-0432 5 Dec 2016
Abbey Court Independent Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led to inaccurate decision-making and documentation.
Philip Evanson
Historic (No Identified Response)
2016-0359 13 Oct 2016
Cheshire Council, Vale Royal Area Highw…
Road (Highways Safety) related deaths
Concerns summary (AI summary) Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are significantly worn and indistinct, posing a safety risk.
Joyce Ravenhill
All Responded
2016-wp25389 24 Aug 2016
North West Ambulance Service Trust NHS
Community health care and emergency services related deaths
Concerns summary (AI summary) A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
1 response from North West Ambulance Service NHS Trust
Kevin Dermott
All Responded
2016-0220 13 Jun 2016
Department for Health NHS England
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Noted (AI summary) NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation in autumn 2016. HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer Custody department for immediate ACCT reviews. Changes are planned for implementation by the end of September 2016. The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately.
Jake Johnson
Historic (No Identified Response)
2014-0417 24 Sep 2014
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack of warning signs, especially near a children's play area.
Christopher Williams
Historic (No Identified Response)
2014-0131 19 Mar 2014
St Mary’s Hospital Warrington
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Carol Ann Gibson
Historic (No Identified Response)
2013-0183 12 Oct 2013
Castlefields Health Centre NHS England
Community health care and emergency services related deaths
Concerns summary (AI summary) A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.