County Durham and Darlington
Coroner Area
Reports: 107
Earliest: Sep 2013
Latest: 17 Mar 2026
85% response rate (above 63% average).
Richard White
All Responded
2014-0085
28 Feb 2014
700 Club
Other related deaths
Concerns summary (AI summary)
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Noted
(AI summary)
The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if handed to them, but will not return it without GP authorisation.
Nathan Douthwaite
Partially Responded
2014-0084
28 Feb 2014
County Durham and Darlington NHS Trust
Department of Health and Social Care
National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
Noted
(AI summary)
The Department of Health acknowledges the coroner's concerns but states that NICE has the statutory function of producing clinical guidelines. NHS England will disseminate the case to NHS learning networks to minimise recurrence.
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 (AI 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 Planned
(AI summary)
The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance arrangements for considering prisoner's requests for private treatment.
Kirk Duboise
Partially Responded
2013-0329
6 Dec 2013
Care UK
Prison Service
State Custody related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing in January 2014, and refresher training on Self Harm Warning Forms is regularly undertaken.
Karl Doran
Historic (No Identified Response)
2013-0328
5 Dec 2013
Beamish Museum
HSE
Other related deaths
Concerns summary (AI 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 (AI 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
(AI summary)
Durham Constabulary now includes face-to-face meetings with certificate holders as part of the structured review process when it would add value, and is rationalising and indexing the 8,500 live certificate files into a more efficient electronic format.
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 (AI 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.