Cornwall and the Isles of Scilly
Coroner Area
Reports: 137
Earliest: Oct 2013
Latest: 16 Feb 2026
80% response rate (above 62% average).
Colin Williams
Historic (No Identified Response)
2016-0008
11 Jan 2016
Cornwall Council Local Adult Safeguardi…
Other related deaths
Concerns 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-wp25058
11 Jan 2016
British Maritime Federation
Royal Yachting Association
Other related deaths
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
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
Partially Responded
2015-0315
7 Aug 2015
Curnow Commissioning Group
NHS England
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
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
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.
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
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
Kernow Clinical Commissioning Group
Department of Health and Social Care
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.
Stuart Long
Historic (No Identified Response)
2014-0320
11 Jul 2014
Cornwall Council
Road (Highways Safety) related deaths
Concerns 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
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
[REDACTED]
Royal Cornwall Hospital Trust
Community health care and emergency services related deaths
Concerns 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
Royal Cornwall Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Aaron Lauder
All Responded
2021-0021
Road (Highways Safety) related deaths
Concerns summary
The primary cause of the collision was an obstructed view for both drivers at the accident site.
Action taken summary
Cornwall Council has agreed to fund a scheme to improve visibility at the farm access by acquiring land and setting back the Cornish hedge, with Cormac’s Safety Engineering team already …