Cornwall and the Isles of Scilly

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

81% response rate (above 63% average).

Response Status
Responded 111 No Response 3 Historic 23
AI Classification
Action Taken 32%
Action Planned 48%
Noted 20%
Disputed 0%
Based on 160 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: +55 reports · +16pp response rate
vs national average: +53 reports · +18pp response rate
137 results
Colin Williams
Historic (No Identified Response)
2016-0008 11 Jan 2016
Cornwall Council Local Adult Safeguardi…
Other related deaths
Concerns summary (AI summary) A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Nicholas Milligan
Historic (No Identified Response)
2016-0007 11 Jan 2016
British Maritime Federation Royal Yachting Association
Other related deaths
Concerns summary (AI summary) The increasing speed and power of power boat leisure craft creates additional risks that users should be aware of to prevent accidents.
Emily Milligan
Historic (No Identified Response)
2016-0007-wp25057 11 Jan 2016
British Maritime Federation Royal Yachting Association
Other related deaths
Concerns summary (AI summary) The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.
Norman Dorn
Historic (No Identified Response)
2016-0006 8 Jan 2016
Care Quality Commission Cornwall and Isles of Scilly Safeguardi…
Care Home Health related deaths
Concerns summary (AI summary) Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
James Adams
All Responded
2015-0315-wp25966 7 Aug 2015
Department of Health and Social Care, C…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable consultant time.
Action Planned (AI summary) • Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group (CCG) to develop a pathway for local implementation of guidance for thromboprohylaxis in ambulatory patients requiring temporary limb immobilisation. • An education programme for the Emergency Department was introduced to support the implementation of the guidance. • The commissioning CCG will monitor implementation and compliance against the guidance through Quality Review Meetings with the Trust. • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG has agreed to carry out a full review both of acute psychiatric beds in Cornwall and the staffing of the place of safety service and will produce an action plan and commissioning strategy. • NHS England will monitor the implementation of this plan.
Miriam Smith-Cox
Partially Responded
2015-0475 24 Jul 2015
Cornwall Council Devon and Cornwall Police Adult Safegua… Pluss Work Choice
Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by a key support stakeholder, preceding a fatal fall.
Noted (AI summary) Pluss states they have a Safeguarding policy and that staff complete 'Alerters' training every 2 years. Pluss will be utilising learning from this unfortunate episode to provide a case study to raise awareness with all Pluss staff, reinforcing their understanding regarding the Safeguarding policy and their responsibilities within it and they will also be carrying out additional Safeguarding, Alerters and Lone Working training with the Truro Team with the company specialist within September. The DWP expresses condolences and explains the benefits claimed by the deceased, as well as detailing the support offered by DWP and its service provider, Pluss. It concludes that Ms Smith-Cox received extensive assistance and was never left without benefit payments.
Shannon Gee
Historic (No Identified Response)
2015-0039 3 Feb 2015
Department of Health and Social Care Kernow Clinical Commissioning Group
Child Death (from 2015) Mental Health related deaths
Concerns summary (AI summary) Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.
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 (AI 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.
Noted (AI summary) The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing bed provision in Cornwall. NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. They are also reviewing provision for individuals placed out of county to inform future commissioning.
Stuart Long
Historic (No Identified Response)
2014-0320 11 Jul 2014
Cornwall Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a place of safety, exposing him to significant danger.
Mrs Care
Historic (No Identified Response)
2014-0273 16 Jun 2014
Royal Cornwall Hospital Truro
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.
Julia Dell
Historic (No Identified Response)
2014-0021 17 Jan 2014
Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall
Community health care and emergency services related deaths
Concerns summary (AI summary) The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Jean James
Historic (No Identified Response)
2013-0207 4 Oct 2013
Rule 43 Archivist, Coroner Society of E… Office of the Chief Coroner Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.