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
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
Tees, Esk and Wear Valleys NHS Foundati… National Institute for Health and Care … South London and Maudsley NHS Foundatio… +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.
Robert Lowe
Historic (No Identified Response)
2019-0319 20 Sep 2019
Chilton Care Centre
Care Home Health related deaths
Concerns summary Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.
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.
Matthew Hamilton
All Responded
2019-0050 14 Feb 2019
HMP Durham
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
John Mayhew
Historic (No Identified Response)
2018-0381 11 Dec 2018
National Offender Management Service HM Inspector of Prisons Independent Advisory Panel on Deaths in…
State Custody related deaths
Concerns summary Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.
Christopher McGuffie
All Responded
2018-0386 10 Dec 2018
Northern Rail Limited
Railway related deaths Suicide (from 2015)
Concerns summary Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Glynn Storey
All Responded
2018-0246 27 Jul 2018
Construction Industry Council
Other related deaths
Concerns summary Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.
Stanley Langdon
Partially Responded
2018-0110 19 Apr 2018
Durham County Council Haven Day Care Centre
Community health care and emergency services related deaths
Concerns summary A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Thomas Whitfield
Historic (No Identified Response)
2017-0126 20 Apr 2017
Tees, Esk and Wear Valleys NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
Warren Myers
Partially Responded
2017-0032 9 Feb 2017
County Durham Council Highways Department
Road (Highways Safety) related deaths
Concerns summary Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
Margaret Atkinson
Partially Responded
2017-0021 30 Jan 2017
G4S Tees, Esk and Wear Valleys NHS Foundati… National Offender Management Service
State Custody related deaths
Concerns summary Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased risk.
Pamela Gower
All Responded
2016-0446 15 Dec 2016
British Parachute Association
Other related deaths
Concerns summary Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such a sport.
Doris Clarkson
All Responded
2016-0423 29 Nov 2016
Lambton Care Home
Care Home Health related deaths
Michelle Barnes
Unknown
24 Oct 2016
State Custody related deaths
Concerns summary Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
Micael McMonigle
Historic (No Identified Response)
2016-0289 15 Aug 2016
Tees, Esk and Wear Valleys NHS Foundati…
Mental Health related deaths
Concerns summary Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and severe delays in responding to a patient's absence, contributed to significant safety concerns.
Pamela Gressman
All Responded
2016-wp25347 1 Aug 2016
Tees, Esk and Wear Valleys NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
Leslie Matthews
Partially Responded
2016-0276 26 Jul 2016
County Durham and Darlington NHS Founda… Medicines and Healthcare Products Regul… Patient Safety Lead
Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths
Nathan Charman
All Responded
2016-0267 21 Jul 2016
Durham County Council
Road (Highways Safety) related deaths
Concerns summary The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.