County Durham and Darlington

Coroner Area
Reports: 107 Earliest: Sep 2013 Latest: 6 Mar 2026

82% response rate (above 62% average).

Response Status
Responded 88 No Response 1 Historic 11 Pending 4
AI Classification
Action Taken 52%
Action Planned 19%
Noted 13%
Disputed 16%
Based on 31 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Other related deaths (17) State Custody related deaths (17) Road (Highways Safety) related dea… (15) Suicide (from 2015) (14)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North East average: +64 reports · +17pp response rate
vs national average: +24 reports · +20pp response rate
107 results
Stanley Cummins
All Responded
2024-0119 4 Mar 2024
County Durham and Darlington NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
Sean Crawford
All Responded
2024-0085 15 Feb 2024
Medicines and Healthcare Products Regul… BNF Publications Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining clozapine with alcohol.
Emily Harkleroad
All Responded
2024-0074 5 Feb 2024
Oracle Health UK County Durham and Darlington NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.
Linda Banks
All Responded
2023-0533 19 Dec 2023
Tees, Esk and Wear Valleys NHS Foundati…
Alcohol, drug and medication related deaths
Concerns summary Identified systemic failures in mental health services were not effectively addressed. Significant delays in Serious Incident Investigations (9 months) compromise evidence quality, hindering prompt learning and improvement in patient safety.
Margaret Heal
Historic (No Identified Response)
2024-0368 6 Dec 2023
REDACTED
Other related deaths
Concerns summary A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.
Margaret Austin
All Responded
2024-0065 27 Nov 2023
Stanley Park Care Centre
Care Home Health related deaths
Concerns summary The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.
Alfie Mains-Forster
All Responded
2023-0459 9 Nov 2023
Clevermed Limited
Child Death (from 2015)
Concerns summary The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart (NEWTT2) remains unimplemented despite being overdue.
Sarah Holmes
All Responded
2023-0383 11 Oct 2023
Care Quality Commission Tees, Esk and Wear Valleys NHS Foundati…
Suicide (from 2015)
Concerns summary The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.
Ian Darwin
All Responded
2023-0291 15 Aug 2023
Tees, Esk and Wear Valleys NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past assurances and national guidelines for 60-day completion.
Kenneth Rippon
All Responded
2023-0268 19 Jul 2023
Care Quality Commission Tees, Esk and Wear Valleys NHS Foundati…
Mental Health related deaths
Concerns summary Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Nicholas Stout
All Responded
2023-0300 15 Jun 2023
Tees, Esk and Wear Valleys NHS Foundati…
Alcohol, drug and medication related deaths
Concerns summary Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Kelly Dunne
All Responded
2023-0088Deceased 13 Mar 2023
Durham County Council
Road (Highways Safety) related deaths
Concerns summary The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being insufficient, untimely, and failing to address the series of junctions, risking further fatal collisions.
Joseph Price
All Responded
2023-0019Deceased 19 Jan 2023
NHS England
Other related deaths State Custody related deaths
Concerns summary Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.
Leanne Dunn
All Responded
2022-0394 8 Dec 2022
Durham County Council
Suicide (from 2015)
Concerns summary A bridge poses a significant risk of death due to an accessible parapet, absence of monitored CCTV and lighting to detect at-risk individuals, and danger to those below from falls.
Michael Smith
All Responded
2022-0417Deceased 10 Nov 2022
HM Prison and Probation Service
State Custody related deaths Suicide (from 2015)
Concerns summary Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Sylvia Gibson
All Responded
2022-0342 27 Oct 2022
Lambton House LTD
Care Home Health related deaths
Concerns summary Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing important patient details with healthcare professionals.
Charles Wheatley
All Responded
2022-0304 29 Jul 2022
Department for Transport
Road (Highways Safety) related deaths
Concerns summary The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.
Claire Copeland
All Responded
2022-0074 8 Mar 2022
Boots UK Ltd Human Kind Charity
Alcohol, drug and medication related deaths Other related deaths
Concerns summary The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, risking discontinuity of vital medical treatment.
Jane Allison
All Responded
2022-0071 7 Mar 2022
Claypath and University Medical Group National Institute for Health and Care … Royal Pharmaceutical Society
Alcohol, drug and medication related deaths Community health care and emergency services related deaths
Concerns summary The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active patients, even for short treatment courses.
Philip Ellis
All Responded
2021-0380 10 Nov 2021
Free the Way
Alcohol, drug and medication related deaths
Concerns summary The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Charlie Todd
All Responded
2021-0318 21 Sep 2021
HMP Durham
State Custody related deaths Suicide (from 2015)
Concerns summary A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.
Joseph Dent
All Responded
2021-0297 6 Sep 2021
Durham County Council
Other related deaths
Concerns summary A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, or detection for at-risk individuals.
Clive Oxley
All Responded
2020-0301 23 Dec 2020
LNER and Network Rail
Railway related deaths
Concerns summary Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, with previous similar incidents noted.
Andrew Westlake
All Responded
2020-0268 3 Dec 2020
Jet2.com Ltd and Civil Aviation Authori…
Mental Health related deaths Other related deaths
Concerns summary Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Claire Richards
Partially Responded
2020-0253 23 Nov 2020
Home Office Royal Pharmaceutical Society
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the leakage of medication from lawful dispensing into criminal hands.