Cumbria
Coroner Area
Reports: 87
Earliest: Aug 2013
Latest: 16 Mar 2026
82% response rate (above 62% average).
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.
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.
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
Russell Long
All Responded
2014-0165
9 Apr 2014
Cumbria County Council
Road (Highways Safety) related deaths
Carl Morris
All Responded
2014-0092
3 Mar 2014
Professional Association of Diving Inst…
Other related deaths
Amanda Vickers
All Responded
2014-0052
3 Feb 2014
NHS Cumbria Clinical Commissioning Group
Mental Health related deaths
Concerns summary
A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.
Martin McGlasson
All Responded
2014-0001
6 Jan 2014
British Precast Concrete Federation
Alcohol, drug and medication related deaths
Concerns summary
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.
Action taken summary
Thomas Armstrong Holdings Ltd has implemented a new system of work and adopted a new Risk Assessment and Method Statement for moving staircases. They have also provided health and safety …
Peter Moorby
All Responded
2022-0194
Cumbria County Council
Alcohol, drug and medication related deaths
Concerns summary
A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a significant risk of future accidental deaths.
Action taken summary
This resident states they have no issue with the low wall but would be willing to contribute to a 'low wall' sign if all residents agreed. They would also consider …