County Durham and Darlington
Coroner Area
Reports: 107
Earliest: Sep 2013
Latest: 17 Mar 2026
85% response rate (above 63% average).
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 (AI summary)
Illegally dealt prescription drugs are of increasing concern, and what steps are projected for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands?
Noted
(AI summary)
The Royal Pharmaceutical Society acknowledges the concerns regarding prescription medicine misuse and highlights their role in promoting best practices, noting that the General Pharmaceutical Council regulates pharmacy. They suggest Public Health England and the Advisory Council for the Misuse of Drugs should be aware of the report.
Jason Thompson
All Responded
2020-0246
20 Nov 2020
Department of Health and Social Care
eBay UK Ltd
Metalchem Ltd
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Action Taken
(AI summary)
Metalchem Ltd stopped selling Sodium Nitrite on eBay in April 2020 after becoming aware of its recommendation on suicide forums. They contacted other sellers to request they stop selling the product online and enlisted help to remove persistent sellers on Ebay and Etsy. Ebay banned the sale of sodium nitrite as a chemical globally in 2019 and updated filters to prevent listings, after a report of potential misuse for suicide attempts. They analyzed the listing from which the deceased purchased the chemical to improve filter algorithms. The Department of Health and Social Care highlights existing actions to reduce suicide rates, including the Suicide Prevention Strategy for England and the Cross-Government Suicide Prevention Workplan, which addresses harmful online content. They are working with online retailers to raise awareness of the potential for suicide and investing in suicide prevention through the NHS Long Term Plan.
William Turner
Partially Responded
2020-0209
15 Oct 2020
Department for Transport
Secretary of State for Transport's Hono…
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The DVLA will ask the Secretary of State for Transport’s Honorary Medical Advisory Panel on Disorders of the Nervous System to review the period of time required off driving before someone who has suffered a seizure can regain their driving licence.
Frazer Golden
All Responded
2020-0197
5 Oct 2020
Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Durham County Council will remove two SLOW road markings and erect bend warning signs on both approaches to the bend. These measures are planned for implementation by 31st March 2021.
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 (AI 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.
Noted
(AI summary)
The Department for Health and Social Care acknowledges the concerns and outlines existing NICE guidance and CQC recommendations regarding the safe use and management of controlled drugs. They highlight the need for regular monitoring of patients before repeat prescriptions are issued.
Viktor Scott-Brown
All Responded
2020-0163
18 Aug 2020
Informa Healthcare
National Institute for Health and Care …
Oxleas NHS Foundation Trust
+2 more
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
Oxleas NHS Foundation Trust states they no longer have any involvement in the authorship or editing of the Maudsley Prescribing Guidelines since April 2015. Tees Esk & Wear Valley NHS Foundation Trust is developing a Medication Safety Series document regarding prescribing resources and sources of patient information, aiming to have a draft ready for approval on 24th September 2020 and complete dissemination by 2nd October 2020. NICE has passed the concerns regarding lamotrigine to the BNF publishers and will consider moving a footnote about the risk of suicidal thoughts and behaviour into the recommendation of their guideline on epilepsies, currently being updated. BNF Publications will add suicidal ideation as a side effect to the lamotrigine monograph and the important safety section of the lamotrigine monograph in the BNF.
Bartosz Kusiak
All Responded
2020-0139
10 Jul 2020
Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
Durham County Council plans to install measures by March 31, 2021, to deter pedestrian access to the A690 dual carriageway, including proactive signage, guardrail, wayfinding signs, foliage clearance, and removal of access to a public footpath.
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 (AI 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.
Action Taken
(AI summary)
Following review, physiotherapists now record changes in mobility or interventions in the Nervecentre system to ensure all staff are aware, in addition to maintaining detailed paper records. A buffer stock of walking aids has also been implemented for out-of-hours emergency use.
David Moore
All Responded
2019-0413
3 Dec 2019
Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Following a fatal accident investigation, the council replaced the pedestrian crossing signs with larger signs manufactured from a highly reflective material.
Robert Lowe
Historic (No Identified Response)
2019-0319
20 Sep 2019
Chilton Care Centre
Care Home Health related deaths
Concerns summary (AI 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 (AI 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.
Action Taken
(AI summary)
The Council reviewed the accident site and, although not considered contributory factors, ordered the recovery of road markings and replacement of defective hazard marker posts. The council also removed hawthorn bushes contributing to reduced visibility.
Matthew Hamilton
All Responded
2019-0050
14 Feb 2019
HMP Durham
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
Action Taken
(AI summary)
HMP Durham's Drug and Alcohol Reduction Team (DART) has updated their guidance pack to be offered to all prisoners on discharge, is offering Naloxone to prisoners at risk of opiate overdose, and has a trained prisoner (DART Mentor) to offer additional harm reduction advice.
John Mayhew
Historic (No Identified Response)
2018-0381
11 Dec 2018
HM Inspector of Prisons
Independent Advisory Panel on Deaths in…
National Offender Management Service
State Custody related deaths
Concerns summary (AI 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 (AI summary)
Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Action Planned
(AI summary)
Arriva Rail North is developing a campaign using various media, providing bespoke training for customer service controllers and are looking to bring forward the planned installation of CCTV at Chester le Street station.
Glynn Storey
All Responded
2018-0246
27 Jul 2018
Construction Industry Council
Other related deaths
Concerns summary (AI summary)
Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.
Noted
(AI summary)
CICAIR clarifies the responsibilities of Approved Inspectors versus builders in ensuring buildings meet safety standards, emphasizing that Approved Inspectors provide a spot-checking process and cannot guarantee compliance. It references existing guidance and complaint procedures.
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 (AI 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.
Action Taken
(AI summary)
The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, and revising home assessment documents.
Thomas Whitfield
Historic (No Identified Response)
2017-0126
20 Apr 2017
Tees, Esk and Wear Valley NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
All Responded
2017-0032
9 Feb 2017
Highways Department, County Durham Coun…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
Action Taken
(AI summary)
Durham County Council increased the size of bend ahead warning signs and re-erected a chevron sign. They have an Accident Investigation and Prevention team that investigates every fatal accident.
Margaret Atkinson
Partially Responded
2017-0021
30 Jan 2017
G4S
National Offender Management Service
Tees, Esk and Wear Valley NHS Trust
State Custody related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The prison Mental Health services are using more specific language than "ligature" to describe observations, discussed in team meetings. The Trust will work with partners to agree and promote a guidance document within the NE prison cluster.
Pamela Gower
All Responded
2016-0446
15 Dec 2016
British Parachute Association
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
For skydive students with non-standard body morphology, the BPA recommends a formal written risk assessment and special consideration for wind tunnel training, possibly with two instructors during AFF levels 4-7.
Doris Clarkson
All Responded
2016-0423
29 Nov 2016
Lambton Care Home
Care Home Health related deaths
Action Taken
(AI summary)
Lambton House is phasing in air flow mattresses compatible with bed sensors and installs bed sensors for users at risk of falls who do not require an air flow mattress. The home now has a standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors.
Michelle Barnes
Historic (No Identified Response)
24 Oct 2016
NOMS, Prison Service, Equality Rights a…
State Custody related deaths
Concerns summary (AI 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 Valley NHS Trust
Mental Health related deaths
Concerns summary (AI summary)
Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Pamela Gressman
All Responded
2016-wp25347
1 Aug 2016
Tees, Esk and Wear Valley
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
1 response
from Tees Esk amd Water Valleys NHS Trust
Leslie Matthews
All Responded
2016-0276
26 Jul 2016
Medicines and Healthcare Products Regul…
Patient Safety Lead, County Durham and …
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Noted
(AI summary)
The MHRA has brought the Coroner's concerns to the attention of the manufacturer and requested that they evaluate whether additional clarity in information could be incorporated at the next Instructions for Use review. They have not identified a systemic problem with cracks associated to Oxylitre flowmeters. All oxygen flowmeters across the Trust have been checked and faults logged. Equipment Controllers/Department Managers are now performing weekly checks of all flowmeters, using a checklist devised by the Medical Devices Nurse.