Cumbria
Coroner Area
Reports: 87
Earliest: Aug 2013
Latest: 16 Mar 2026
82% response rate (above 62% average).
Gordon Hendley
Historic (No Identified Response)
2022-0217
14 Jul 2022
North Cumbria Integrated Care Trust
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary
Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.
Mary Nelson
Historic (No Identified Response)
2020-0036
24 Feb 2020
Medicines and Healthcare Products Regul…
Alcohol, drug and medication related deaths
Concerns summary
Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
Rebecca Quail
Historic (No Identified Response)
2019-0242
18 Jul 2019
DVSA
Road (Highways Safety) related deaths
Concerns summary
Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to foreign objects not visible on visual inspection.
Kevin Ritson
Historic (No Identified Response)
2016-wp25356
10 Aug 2016
Cumbria County Council
Highways Department
Road (Highways Safety) related deaths
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.
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.
Elizabeth Cooper
Historic (No Identified Response)
2014-0197
1 May 2014
National Institute for Health and Care …
General Medical Council
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.
Michael Telford
Historic (No Identified Response)
2014-0045
3 Feb 2014
Cumbria County Council
Road (Highways Safety) related deaths
Brian Belfield
Historic (No Identified Response)
2013-0270
21 Oct 2013
Fell Runners Association
Other related deaths
Concerns summary
Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control and marshals, leading to a missing runner.
Matthew Thomas Hamilton
Historic (No Identified Response)
2013-0180
8 Aug 2013
Cumbria County Council
Road (Highways Safety) related deaths
Concerns summary
A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.