Cumbria
Coroner Area
Reports: 87
Earliest: Aug 2013
Latest: 16 Mar 2026
82% response rate (above 62% average).
Karen Edgar
Partially Responded
2018-0106
16 Apr 2018
Morecambe Bay Clinical Commissioning Gr…
Cumbria Partnership NHS Foundation Trust
North Cumbria Clinical Commissioning Gr…
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.
Sharon Grierson
All Responded
2018-0034
25 Jan 2018
Department for Health
North Cumbria University Hospital NHS T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need for better training in emergency management.
Kathleen Holme
All Responded
2017-0212
18 Sep 2017
SC Johnson and Son
Other related deaths
Concerns summary
The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being too small on packaging and absent from the device itself.
Jeffery Matthews
All Responded
2017-0230
6 Sep 2017
Cumbria County Council
Road (Highways Safety) related deaths
Concerns summary
Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended safety improvements due to resource issues, created a significant risk.
Amanda Coulthard
All Responded
2017-0024
18 Jan 2017
Department of Health and Social Care
North Cumbria University NHS Trust: NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."
Michael Parke
All Responded
2017-0025
18 Jan 2017
Department of Health and Social Care
North Cumbria University NHS Trust: NHS…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."
Frazer Livesey
All Responded
2016-0418
21 Nov 2016
Impact Housing Association
Community health care and emergency services related deaths
Other related deaths
Concerns summary
Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Kevin Ritson
Historic (No Identified Response)
2016-wp25356
10 Aug 2016
Cumbria County Council
Highways Department
Road (Highways Safety) related deaths
Constance Pridmore
All Responded
2016-0491
12 May 2016
Department of Health and Social Care
University Hospitals of Morecambe Bay N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.
Tony Jopson and Michael Jopson
All Responded
2016-0172
4 May 2016
Department for Transport
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary
The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual carriageway throughout.
Michael Jopson
All Responded
2016-wp25249
4 May 2016
Department for Transport
Road (Highways Safety) related deaths
Andrew Coates
All Responded
2016-0025
28 Jan 2016
Cumbria County Council
Other related deaths
Concerns summary
An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.
Richard Green
Partially Responded
2015-0456
2 Nov 2015
National Offender Management Service
Ministry of Justice
State Custody related deaths
Concerns summary
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Violet Cloudsdale
Historic (No Identified Response)
2015-0387
25 Sep 2015
Care Quality Commission
Risedale Estates Limited
Care Home Health related deaths
Concerns summary
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Michael Hanlon
All Responded
2015-0294
23 Jul 2015
Plateus Ltd
Accident at Work and Health and Safety related deaths
Concerns summary
An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Meryl Parry
Partially Responded
2015-0259
8 Jul 2015
Green Lane Care Homes Limited
Cumbria County Council
Other related deaths
Concerns summary
A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not have appropriate safety and welfare arrangements in place.
Alice McMeekin
Historic (No Identified Response)
2015-0211
4 Jun 2015
Cumbria Constabulary
Cumbria Partnership NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Police related deaths
Concerns summary
Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.
Mark Foley
Partially Responded
2015-0204-wp24839
1 Jun 2015
Minister of Defence
British Army
Service Personnel related deaths
Concerns summary
Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led to the fatal incident.
Alexander Ball
All Responded
2015-0069
19 Feb 2015
Cumbria Partnership NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care coordination for complex patients.
William Jackson
All Responded
2014-0509
24 Nov 2014
Newcastle Foundation NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.
Helena Farrell
All Responded
2014-0309
3 Jul 2014
Cumbria County Council
Cumbria Partnership NHS Foundation Trust
Community health care and emergency services related deaths
Concerns summary
Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified qualifications and professional oversight.
Ian Reid
All Responded
2014-0288
30 Jun 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
James Boylan
Partially Responded
2014-0253
6 Jun 2014
Care Quality Commission
NHS England
Department of Health and Social Care
+2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.
Elizabeth Cooper
Historic (No Identified Response)
2014-0197
1 May 2014
General Medical Council
National Institute for Health and Care …
Community health care and emergency services related deaths
Concerns summary
No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.
Russell Long
All Responded
2014-0165
9 Apr 2014
Cumbria County Council
Road (Highways Safety) related deaths