County Durham and Darlington

Coroner Area
Reports: 107 Earliest: Sep 2013 Latest: 17 Mar 2026

85% response rate (above 63% average).

Response Status
Responded 91 No Response 2 Historic 14
AI Classification
Action Taken 47%
Action Planned 30%
Noted 21%
Disputed 1%
Based on 135 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Other related deaths (17) State Custody related deaths (17) Suicide (from 2015) (15) Road (Highways Safety) related dea… (14)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North East average: +63 reports · +19pp response rate
vs national average: +23 reports · +22pp response rate
107 results
Nathan Charman
All Responded
2016-0267 21 Jul 2016
Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Durham County Council reviewed the incident and has amended the Winter Maintenance Operational Plan to align gritting route 28 to the Low Pennines weather forecasting domain and to confirm that Duty Managers and Decision Validators must not use professional judgement to reduce the margin of safety.
James Kane
All Responded
2016-0253 15 Jul 2016
County Durham and Darlington NHS Trust Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.
Noted (AI summary) The Department of Health consulted NICE and the Royal College of Radiologists and concluded that there is no case for the routine use of ultrasound prior to or during paracentesis, but highlighted the concerns to the NICE guideline surveillance team for consideration in future updates. County Durham and Darlington NHS Trust will provide all trainees with a copy of the guidance regarding large volume paracentesis, ensure a clear audit trail of patients undergoing paracentesis (including a proforma and database), and perform all procedures between 8am and 8pm; a patient information leaflet will also be available.
John Betteridge
Historic (No Identified Response)
2016-0238 30 Jun 2016
G4S National Offender Management Service NHS England +1 more
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Elsie Raper
All Responded
2016-0090 4 Mar 2016
County Durham and Darlington NHS Trust,… Neasham Road Surgery
Care Home Health related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Action Planned (AI summary) The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion of the issues with the staff at Grosvenor Park Care Home. Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate details associated with a diagnosis of osteoporosis and increased risk of fracture, and now refers residents to the Community Matron for review after low impact falls.
James Graham
Historic (No Identified Response)
17 Dec 2015
G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant delays in secondary care access.
Derek Thomas
Partially Responded
2015-0502 15 Dec 2015
CARE UK G4S GEOAmey +2 more
State Custody related deaths
Concerns summary (AI summary) Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Noted (AI summary) Nursing staff have been instructed to review all documents when completing reception screening, and staff have been reminded of the importance of ensuring all paperwork accompanies an individual. All initial healthcare assessments are undertaken by qualified mental health nurses, unless circumstances prevent this. The prison has implemented mandatory verbal handover of SASH form information from reception staff to healthcare staff. All staff working in reception must complete an online training course, managed by their line manager and monitored through the staff appraisal system. Care UK is no longer the healthcare provider at HMP Durham. It will forward the concerns to heads of healthcare at other facilities where it interacts with GEO Amey and the prison service. GEOAmey provided refresher training to over 90% of their officers regarding the completion of Prisoner Escort Records (PER) and Self Harm and Suicide Warning Forms (SASH Forms), following concerns raised about procedures and training.
Kevin Forster
All Responded
2015-0453 28 Oct 2015
G4S National Offender Management Service
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Action Taken (AI summary) Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.
Kyle Hull
All Responded
2015-0379 19 Oct 2015
Darlington Cattle Mart
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.
Action Planned (AI summary) The auction mart company plans to install CCTV with night vision and movement detection, linked to mobile phones of company management, but is currently seeking financing; a final decision is expected at the December board meeting.
Charles Rayner
Historic (No Identified Response)
2015-0367 1 Oct 2015
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) The report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right turns with appropriate signage.
Kenneth McCurdy and Mary McCurdy
All Responded
2015-0369 1 Oct 2015
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns for east-bound vehicles, creating a significant highway safety risk.
Action Planned (AI summary) Highways England will work with Durham Constabulary to investigate enhancements to signing and road markings on the A66 by March 2016. They will also place a bid for funding to undertake the work recommended by the investigations.
Patricia Chapman
All Responded
2015-0159 23 Apr 2015
County Durham and Darlington NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.
Action Taken (AI summary) The Trust has trained qualified staff at Sedgefield Community Hospital in managing deteriorating patients and hypoglycemia. They have introduced an operational procedure for community hospital staff to seek urgent advice from acute hospital staff while waiting for an ambulance, including contact numbers for medical consultants and registrars.
Stephen Myers
Partially Responded
2015-0150 15 Apr 2015
Department of Business, Innovations and… General Product Safety Department
Product related deaths
Concerns summary (AI summary) A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.
Noted (AI summary) The Department for Business, Innovation and Skills clarifies that responsibility for labelling of "poppers" rests with the Health and Safety Executive and enforcement with local Trading Standards. It states that General Product Safety Regulations would not have been breached in this case as instructions for use were not followed and the Home Office tackles new psychoactive substances.
Sharon Butcher
Partially Responded
2015-0129 31 Mar 2015
HMP Frankland National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Action Taken (AI summary) HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies.
Andrea Thirkell
Historic (No Identified Response)
2015-0124 30 Mar 2015
Darlington Memorial Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.
Grant Benson and Gordon Davidson
All Responded
2015-0102 18 Mar 2015
Yorkshire Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary) Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented effective call transfer or dispatch of a nearby ambulance, causing critical delays.
Action Taken (AI summary) County Durham and Darlington Fire and Rescue Service introduced a new mobilising and communications system in December 2014 and reviewed call handling procedures for adjoining emergency services, updating contact information and communication protocols. North East Ambulance Service has reviewed processes and systems for cross-border incidents, passed information to the training department to review call handling procedures and clarified the circumstances under which mutual aid agreements would be used.
Andrew Peacock
All Responded
2015-0086 9 Mar 2015
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may reduce visibility and increase collision risk for other road users.
Noted (AI summary) The Department for Transport acknowledges the coroner's concerns regarding amber warning beacons on agricultural vehicles but states that current data does not support making them mandatory. They highlight existing initiatives for motorcyclist safety and will retain the information for future consideration.
Thomas Taylor
Historic (No Identified Response)
2015-0076 3 Mar 2015
County Durham and Darlington NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.
Jordan Roberts
Partially Responded
2015-0042 6 Feb 2015
Durham County Council Finchale Abbey Farm
Other related deaths
Concerns summary (AI summary) Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong currents in the River Wear, leaving river path users unaware.
Action Taken (AI summary) Larger, improved hazard warning signs have been erected at 3 key locations along the northern river bank and additional work will be undertaken to improve sections of fencing along the northern side of the river bank. Information will also be provided on the Durham County Council Cocken Wood picnic area webpages regarding the hazards associated with the river.
Geraldine Kilborn
All Responded
2014-0532 10 Dec 2014
Care UK National Offender Management Service Tees Esk Wear Valley NHS Foundation Tru…
State Custody related deaths
Concerns summary (AI summary) There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Action Planned (AI summary) An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team. From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated for, Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review. TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.
David Greenfield
All Responded
2014-0518 27 Nov 2014
Priory Group Ltd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.
Action Taken (AI summary) The Priory Group audited the competencies of medical staff in specialist wards and provided additional training where needed. They are ensuring a full baseline physical health assessment is in place at the point of admission. They reviewed practices and will ensure that all hospitals have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs.
Jeffrey Gash
All Responded
2014-0377 18 Aug 2014
Tees, Esk and Wear Valleys NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading to poor risk assessment. The clinical risk policy was unclear for non-in-person assessments.
Action Taken (AI summary) Following the inquest, the individual nurse received capability management and observed best practices. The Trust is reviewing policy and practice, planning further suicide prevention training, and monitoring implementation via the Directorate's Quality Assurance Group. Trust-wide actions will be allocated to an owner and monitored by the Patient Safety Team.
Gary Million
Historic (No Identified Response)
2014-0348 29 Jul 2014
North East Ambulance Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and inadequate communication protocols with BT. Subsequent investigations and revised protocols were also insufficient and poorly implemented.
Edward Devlin
Partially Responded
2014-0335 22 Jul 2014
Care UK HMP Durham National Offender Management Service +1 more
State Custody related deaths
Concerns summary (AI summary) Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Action Planned (AI summary) Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence.
Sopefoluwa Peters
All Responded
2014-0206 8 May 2014
Durham County Council
Other related deaths
Concerns summary (AI summary) Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Action Planned (AI summary) The Council will install a timber barrier in the riverside footpath adjacent to the wall opposite the exit of Drury Lane. The County Council will also be undertaking a risk assessment along sections of the river bank.
Melvin Bandtock
All Responded
2014-0147 3 Apr 2014
Durham Constabulary Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures are needed.
Disputed (AI summary) The Council intends to meet with weather forecasters prior to the next winter season to determine whether notifications relating to changes in weather can be improved. Duty Managers have been reminded to ensure that appropriate action is taken and the safety of the highway network is the paramount consideration. The Constabulary disputes the coroner's concern, stating that their procedures for dealing with road incidents are not managed on an ad-hoc basis and that they have robust, well-managed procedures and good communication with Durham County Council.