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 52%
Action Planned 29%
Noted 15%
Disputed 5%
Based on 62 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
Clear 94 results
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Concerns summary Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.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
Medicines and Healthcare products Regul… Cornwall Council
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.
Benjamin Williamson
All Responded
2018-0384 12 Dec 2018
Kernow Clinical Commissioning Group Addaction
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.
Thomas Curtin
All Responded
2018-0076 14 Mar 2018
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.
Pauline Pryor
All Responded
2018-0009 12 Jan 2018
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.
David Buttriss
All Responded
2018-0010 12 Jan 2018
Cornwall Health Cornwall NHS Trust NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.
Anna Phillips
All Responded
2017-0033 8 Feb 2017
Home Office
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Simon Charles
All Responded
2016-0465 28 Dec 2016
South West National Trust
Other related deaths
Concerns summary Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.
Dorethea Parr
All Responded
2016-0466 28 Dec 2016
Cornwall Partnership Foundation Trust
Community health care and emergency services related deaths
Concerns summary Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.
Margaret Wakefield
All Responded
2016-0413 14 Nov 2016
Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.
David Knight
All Responded
2016-0414 14 Nov 2016
Department for Health NHS England
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.
Danny Sweet
All Responded
2016-wp25341 29 Jul 2016
Cornwall Partnership Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Beverley Siddall
All Responded
2016-0230 24 May 2016
Cornwall Council
Road (Highways Safety) related deaths
Concerns summary The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles leaving the road.
George Taylor
All Responded
2015-0044 2 Feb 2015
Department of Health and Social Care Kernow Clinical Commissioning Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.