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
Richard White
All Responded
2014-0085 28 Feb 2014
700 Club
Other related deaths
Concerns summary Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Zeeyad Hamadi
Partially Responded
2014-0014 13 Jan 2014
Department of Health and Social Care National Offender Management Service
State Custody related deaths
Concerns summary Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Action taken summary The Department of Health acknowledges the concerns regarding prisoner healthcare but states that responsibility for these matters now rests with NHS England. They have forwarded the report to NHS Engl
Kirk Duboise
All Responded
2013-0329 6 Dec 2013
State Custody related deaths
Concerns summary There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Karl Doran
Unknown
2013-0328 5 Dec 2013
Other related deaths
Concerns summary The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their activities.
Robert Wilkinson
All Responded
2013-0269 21 Oct 2013
Durham Constabulary
Product related deaths
Concerns summary The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access to weapons.
Action taken summary Durham Constabulary states that face-to-face meetings will now be undertaken when they add value to firearms license reviews. They are also addressing weaknesses in record keeping by converting all ce
Linda Hudson
Historic (No Identified Response)
2013-0243 24 Sep 2013
Tees, Esk and Wear Valleys NHS Foundati…
Community health care and emergency services related deaths
Concerns summary Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Mina Topley-Bird
All Responded
2021-0100
Department of Health and Social Care West Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.
Action taken summary Tees, Esk and Wear Valleys NHS Foundation Trust immediately implemented a checklist for Accident and Emergency patients from outside the area to ensure information gathering and sharing. They are also