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
Clear 72 results
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
Human Kind Charity Boots UK Ltd
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
Royal Pharmaceutical Society National Institute for Health and Care … Claypath and University Medical Group
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.
Jason Thompson
All Responded
2020-0246 20 Nov 2020
Metalchem Ltd eBay UK Ltd Department of Health and Social Care
Mental Health related deaths Suicide (from 2015)
Concerns summary A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety risks.
William Turner
All Responded
2020-0209 15 Oct 2020
Department for Transport
Road (Highways Safety) related deaths
Concerns summary Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to a fatal incident.
Frazer Golden
All Responded
2020-0197 5 Oct 2020
Durham County Council
Road (Highways Safety) related deaths
Concerns summary Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on a bend with reduced visibility created a dangerous road environment.
Laura Parsons
All Responded
2020-0170 3 Sep 2020
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the overdose history during repeat prescription authorization, lacking critical scrutiny.
Viktor Scott-Brown
All Responded
2020-0163 18 Aug 2020
South London and Maudsley NHS Foundatio… Tees, Esk and Wear Valleys NHS Foundati… Informa Healthcare +2 more
Community health care and emergency services related deaths Suicide (from 2015)
Concerns summary A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.
Bartosz Kusiak
All Responded
2020-0139 10 Jul 2020
Durham County Council
Road (Highways Safety) related deaths
Concerns summary An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility for drivers was inadequate, making emergency stops impossible within the available range.
Agnes Sansom
All Responded
2020-0002 7 Jan 2020
County Durham and Darlington NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
David Moore
All Responded
2019-0413 3 Dec 2019
Durham County Council
Road (Highways Safety) related deaths
Concerns summary A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit and no street lighting, creates a critical hazard where vehicle stopping distances exceed driver visibility.
Shaun Neal
All Responded
2019-0009 15 Apr 2019
Durham County Council
Road (Highways Safety) related deaths
Concerns summary The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about road safety markings.