Cornwall and the Isles of Scilly

Coroner Area
Reports: 137 Earliest: Oct 2013 Latest: 16 Feb 2026

81% response rate (above 63% average).

137 results
Christopher Stevens
All Responded
2023-0204 22 Jun 2023
CPFT
Suicide (from 2015)
Concerns summary (AI summary) Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient leave, has been significantly delayed, raising concerns about ongoing risks.
Action Planned (AI summary) Lincolnshire County Council will regularly assess vegetation at the junction approaches and take action to ensure maximum visibility. They concluded that the existing visibility exceeds requirements for a STOP sign and will not change the existing GIVE WAY signage. Regenesis Health Travel Ltd is preparing a court case against the Termessos Hospital and the doctor(s) regarding the patient's death, planned to start in the next 3-5 months. They also state they no longer have a contract with the hospital.
Kaius Tutt
All Responded
2023-0169 22 May 2023
Connectivity and Environment
Road (Highways Safety) related deaths
Concerns summary (AI summary) Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous downhill overtaking section lacks funding for implementation.
Action Taken (AI summary) The Highway Authority has arranged for the relevant downhill overtaking section to be removed on the A391 at Carclaze, St Austell.
Julie Hancock
All Responded
2023-0159 15 May 2023
Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.
Action Taken (AI summary) The Trust identified the prescribing doctor, clarified the policy ambiguity through the Thrombosis Prevention and Anticoagulation Steering Group, and will audit recently uploaded policies to ensure correct procedures were followed.
Tamsin Dolamore
All Responded
2023-0160 12 May 2023
Devon and Cornwall Police Network Rail Police and Crime Commissioner
Other related deaths
Concerns summary (AI summary) High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of work.
Noted (AI summary) Dorset Police are launching Project Synergy to improve their investigative operating model and increase the resilience and wellbeing of investigative teams. They are recruiting a Detective Chief Superintendent to lead the project, which includes forming investigative hubs and introducing investigation support officers. The Ministry of Justice acknowledges the coroner's recommendations and highlights existing and planned government actions related to funding victim support services, improving SARC provisions, and implementing the Victims and Prisoners Bill. Response notes Chief Constable will address concerns about rape investigation caseload. Network Rail has instructed the raising of the parapet at Menacuddle Hill/North Street Bridge to a minimum of 1250mm above adjacent surface level, with an additional course of stonework from an existing minimum height of 990mm. The current timescale for completion of the project is one year from instruction. Cornwall Council acknowledges the complexity of funding for sexual violence recovery services and states that there is no record of Ms. Dolamore having contact with the Council's children's or adult social care services. It describes the Early Help Hub and training offered to professionals.
John Roberts
All Responded
2023-0135 25 Apr 2023
National Institute for Health and Care … Royal Cornwall Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel perforation risk for diverticular disease patients.
Noted (AI summary) The Trust provides a chronology of events regarding a prednisolone dosage reduction error and states that the treating and discharging physicians were aware of the dosage error and that it caused no harm to Mr. Roberts, therefore requiring no action by the GP. BNF Publications will add "diverticular disease (increased risk of diverticular perforation)" to the "Cautions" section of all corticosteroid monographs in the BNF, actioned for the August online monthly update.
Lugh Baker
All Responded
2023-0090Deceased 13 Mar 2023
Bowden Derra Park Ltd
Care Home Health related deaths
Concerns summary (AI summary) The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.
Action Taken (AI summary) The facility has updated its Nocturnal CCTV Monitoring Chart to include a comments box for explaining gaps in monitoring. They have also updated their Care Plan and Training policies, with staff notified and tracked via the BrightHR application.
Sharon Harman
All Responded
2023-0072Deceased 24 Feb 2023
Minister of State for Crime, Policing a…
Other related deaths
Concerns summary (AI summary) Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked legal power to retain a suspect's house key.
Action Planned (AI summary) The Home Office will raise discrepancies between College of Policing guidance and PACE powers with the College of Policing. They describe plans for Domestic Abuse Protection Notices and Orders, and reference the Tackling Domestic Abuse Plan.
James Parsons
All Responded
2023-0069Deceased 22 Feb 2023
Cornwall Council, Porthleven Harbour & …
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions for anyone falling into the water.
Noted (AI summary) Cornwall Council is awaiting a response from the Porthleven Food Festival event organiser regarding additional safety measures. The council will also write to all harbours and event organisers for events near harbours, making them aware of the incident and asking them to consider harbour edges as part of their risk assessment process, to be completed by the end of April 2023. The HSE clarifies its regulatory remit regarding Porthleven Harbour, stating it only applies where a work activity is taking place. It states that vires in relation to festivals and other public events falls to the Local Authority, in this case the licensing arm of Cornwall Council and their Environmental Health Office (EHO). The HSE will visit to review the health and safety arrangements at the commercial crabbing area. Porthleven Harbour & Dock Company expresses condolences and states that the Porthleven Food Festival is responsible for all health and safety matters. They state that there is no evidence of where the deceased fell into the water or that he fell at all and that the report does not point to failure of the Harbour & Dock Company to recognise potential public danger. They are committed to ongoing reviews of health and safety issues.
Felice Banfield
Historic (No Identified Response)
2023-0032Deceased 30 Jan 2023
Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to missed patient deterioration.
Daniel Tilley
All Responded
2022-0393 6 Dec 2022
Devon and Cornwall Constabulary
Suicide (from 2015)
Concerns summary (AI summary) Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely responses to incidents, a long-standing issue particularly acute during peak demand.
Noted (AI summary) The Home Office acknowledges the coroner's concerns and outlines the government's commitment to providing resources to the police, including increasing officer numbers and funding for Devon and Cornwall Police. They also mention plans to introduce a new police funding formula. Devon and Cornwall Police detailed actions taken to address staffing and workload challenges in their CMCUs, including improvements in demand response times, implementation of wellbeing initiatives for personnel, and a process for recording and implementing learning from each summer period.
Tina Allen
All Responded
2022-0391 5 Dec 2022
Home Farm Trust Limited
Care Home Health related deaths
Concerns summary (AI summary) Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.
Action Taken (AI summary) HFT has made improvements to service provision at Valley View, commissioning an independent review and working with stakeholders. They have increased staffing levels, provided training on specific health conditions, implemented a new digital care planning system, and enhanced the Quality Assurance Framework.
Anthony Reedman
Partially Responded
2022-0375 22 Nov 2022
NHS England North Bristol NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The lack of a 24/7 thrombectomy service in Cornwall creates a "postcode lottery" for stroke patients, compounded by the absence of a service level agreement with the nearest specialist unit.
Action Planned (AI summary) North Bristol NHS Trust will explore with University Hospitals Plymouth and Royal Cornwall Hospital Trust what support they can offer for out-of-region referrals as UHP transitions to a 24/7 thrombectomy service in October 2023.
David Morganti, Winnie Barnes, Robert Conybeare and Anthony Reedman
All Responded
2022-0359 10 Nov 2022
Department of Health and Social Care
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.
Action Planned (AI summary) Cornwall Council has commissioned additional capacity at the Frances Bolitho care home, creating 33 new residential and nursing dementia beds and entered into a partnership with Sanctuary Housing Association. Cornwall Council has relaunched the proud to care Cornwall recruitment campaign to support providers with their recruitment of care staff. The Department of Health and Social Care is addressing concerns raised by the coroner through national initiatives, including the Urgent and Emergency Care Services Recovery Plan, which aims to reduce A&E and ambulance wait times. The Government's Primary Care Recovery Plan, currently being drafted, will respond to the challenges facing general practice.
Harry Evans
All Responded
2022-0353 4 Nov 2022
Exeter University
Suicide (from 2015)
Concerns summary (AI summary) The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.
Action Planned (AI summary) The University of Exeter has reviewed mental health awareness training, consolidating courses and clarifying attendance. They are also progressing replacement of the CMS, through the procurement of a new case management product, with implementation aimed for the 2023/24 academic year, and have introduced a welfare tracker to track case progress.
Paul Welch
All Responded
2022-0178 15 Jun 2022
Cornwall Council and Mylor Parish Counc…
Other related deaths
Concerns summary (AI summary) Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.
Action Planned (AI summary) Planning and Housing Cornwall Council is expediting the application for tree works, including internal consultations, with a decision expected before the end of the month; they have also scheduled a meeting for consultation. Sailors Creek CIC hand-delivered letters, posted safety notices, removed mooring ropes from trees, held a site meeting with concerned parties, and adapted their risk assessment and safety brief. They have also implemented a temporary system for positioning moored boats further into the creek, and plan to replant trees and develop a tree management plan by the end of September 2022, and complete the mooring chain along the length of the beach by the end of 2022.
Ryan Taylor
All Responded
2022-0418Deceased 25 May 2022
Cormac and Cornwall Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible improvements.
Action Taken (AI summary) Cormac and Cornwall Council report that they have completed significant drainage improvements in the area of the accident, including installing nearly 500m of combined kerb drainage and increasing the capacity of over 400m of underlying carrier drains.
Laura Smallwood
All Responded
2022-0109 7 Apr 2022
Minister for Crime and Policing
Other related deaths
Concerns summary (AI summary) The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.
Noted (AI summary) The Home Office acknowledges the concerns raised, explains the existing legislative framework, and states that it prefers to encourage sensible planning rather than mandating every element of it through legislation, pointing to guidance from the Cabinet Office.
Jake Cahill
All Responded
2022-0032 1 Feb 2022
Youth Justice Board for England and Wal…
Child Death (from 2015) Other related deaths Suicide (from 2015)
Concerns summary (AI summary) Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Action Taken (AI summary) The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family and health.
Coco Bradford
All Responded
2022-0012 18 Jan 2022
National Institute for Health & Care Ex…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.
Action Planned (AI summary) NICE acknowledges the guideline on gastroenteritis in under 5s [CG84] does not align with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support, and has forwarded the report to their guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.
Emma Burbury
All Responded
2021-0382 11 Nov 2021
Cornwall Council Kernow Clinical Commissioning Group
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Action Planned (AI summary) The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway to address collaborative working between the ICMHT and other partners. NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will ensure WAWY staff complete specific training modules.
Kirsty Doodes
All Responded
2021-0343 14 Oct 2021
Cornwall Partnership (Foundation) Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.
Action Planned (AI summary) The Trust is taking measures to expand the mental health workforce, including international nurse recruitment, increasing apprentice roles, and improving staff retention.
Frankie Macritchie
Partially Responded
2021-0315 17 Sep 2021
Devon and Cornwall Police Constabulary Dog Legislation Office
Child Death (from 2015) Other related deaths Police related deaths
Concerns summary (AI summary) Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future serious incidents.
Noted (AI summary) Devon and Cornwall Police are assured that they are dealing with reports appropriately where a dog poses a risk of serious harm, and will explore with the Police and Crime Commissioner the opportunities for enhanced public communication, potentially with our farming community and Local Authority partners in respect of dangerous dogs.
Ryan Taylor
All Responded
2021-0176 25 May 2021
Cornwall Council and CORMAC
Road (Highways Safety) related deaths
Concerns summary (AI summary) Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.
Action Planned (AI summary) Cornwall Council will erect signs warning of surface water, replace gully grids with larger capacity gratings in October, and undertake detailed drainage and topographical surveys. Further upgrades to the drainage system may be designed and implemented after the survey information is obtained.
Helen Spicer
All Responded
2021-0127 7 May 2021
Chair of the Advisory Council on the Mi…
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured medication reviews in primary care. The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request information from DHSC and NHS-E&I regarding patient safety incidents.
Caitlin Swan
All Responded
2021-0121 27 Apr 2021
CORMAC – Cornwall Council – Highways De…
Road (Highways Safety) related deaths
Concerns summary (AI summary) A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar with the acute turn and stationary vehicles.
Action Planned (AI summary) Cornwall Council will erect additional warning signs at the Trebost junction at Tubbon Hill, following the coroner's recommendation.