Cornwall and the Isles of Scilly

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

80% response rate (above 62% average).

Response Status
Responded 110 No Response 3 Historic 23 Pending 1
AI Classification
Action Taken 59%
Action Planned 27%
Noted 11%
Disputed 3%
Based on 37 classified responses
Top Categories
Hospital Death (Clinical Procedure… (46) Other related deaths (26) Suicide (from 2015) (19) Alcohol, drug and medication relat… (18) Mental Health related deaths (15)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: +56 reports · +16pp response rate
vs national average: +54 reports · +18pp response rate
137 results
Katie Corrigan
All Responded
2021-0045 17 Feb 2021
Primary Medical Services and Integrated…
Alcohol, drug and medication related deaths Other related deaths
Concerns summary There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Partially Responded
2020-0274 7 Dec 2020
Department of Business Office for Product Safety and Standards Energy and Industrial Strategy
Product related deaths
Concerns summary The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack of mandatory recording impedes urgent communication and tracing between stakeholders.
Darrell Sharples
All Responded
2020-0219 28 Oct 2020
Devon and Cornwall Constabulary
Mental Health related deaths Suicide (from 2015)
Concerns summary A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Raymond Woodhouse
Historic (No Identified Response)
2020-0217 21 Oct 2020
Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.
Avis Addison
All Responded
2020-0216 14 Oct 2020
Care Quality Commission
Other related deaths
Concerns summary Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Jan Klempar
All Responded
2020-0152 7 Aug 2020
Maritime Coastguard Agency Royal National Lifeboat Institution
Other related deaths
Concerns summary Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Anthony Williamson
All Responded
2020-0153 7 Aug 2020
Maritime Coastguard Agency Royal National Lifeboat Institution
Other related deaths
Concerns summary Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Gillian Davey
All Responded
2020-0121 28 May 2020
Royal National Lifeboat Institute Department for Transport Maritime and Coastguard Agency
Other related deaths
Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Michael Pender
All Responded
2020-0122 28 May 2020
Royal National Lifeboat Institute Maritime and Coastguard Agency Department for Transport
Other related deaths
Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Marc Cole
All Responded
2020-0087 6 Feb 2020
College of Policing Home Office
Alcohol, drug and medication related deaths Police related deaths
Concerns summary There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe use.
REDACTED
Historic (No Identified Response)
2019-0397 22 Nov 2019
College of Policing
Suicide (from 2015)
Concerns summary Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.
Ian Bean
Historic (No Identified Response)
2019-0340 10 Oct 2019
East Midlands Ambulance Service
Emergency services related deaths (2019 onwards) Suicide (from 2015)
Concerns summary An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.
Emily Sims
All Responded
2019-0336 9 Oct 2019
Antron Manor Care Home
Care Home Health related deaths
Concerns summary Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.
Dylan Henty
All Responded
2019-0334 8 Oct 2019
Pentree Lodge Home
Care Home Health related deaths
Concerns summary Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.
Geraint Hughes
All Responded
2019-0268 18 Aug 2019
Cornwall Partnershipship NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.
Jennifer Withey
All Responded
2019-0225 3 Jul 2019
NHS England NHS Pathways
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient care.
Michael Cox
All Responded
2019-0203 20 Jun 2019
Cornwall Council
Care Home Health related deaths Mental Health related deaths
Concerns summary There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.
Jeanette Robinson
All Responded
2019-0185 3 Jun 2019
Cornwall Council Medicines and Healthcare products Regul…
Community health care and emergency services related deaths
Concerns summary An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.
Paul Gillam
Partially Responded
2019-0045 11 Feb 2019
Alcohol Action Team Cornwall Council Cornwall NHS Trust Drug +1 more
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between Addaction and the Community Mental Health Team.
Benjamin Williamson
All Responded
2018-0384 12 Dec 2018
Addaction Kernow Clinical Commissioning Group
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for information sharing, creating a significant care gap.
David Sargeant
All Responded
2018-0312 25 Oct 2018
Kernow Clinical Commissioning Group
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county referrals for ongoing care.
Phylliss Letcher
All Responded
2018-0276 6 Aug 2018
Crossroads House Care Home
Care Home Health related deaths
Concerns summary The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating unrestricted access to dangerous areas.
William Watson
All Responded
2018-0237 19 Jul 2018
Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking avoidable deaths.
Marcus Hance
Partially Responded
2018-0173 7 Jun 2018
Cornwall NHS Trust NHS Kernow Clinical Commissioning Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to crucial mental health care.
Hans-Peter Schmidt
Historic (No Identified Response)
2018-0145 14 May 2018
Cornwall Council Heritage Attractions Ltd Lands End Resort
Other related deaths
Concerns summary Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot spots create significant safety hazards.