Plymouth, Torbay and South Devon
Coroner Area
Reports: 119
Earliest: Sep 2013
Latest: 9 Mar 2026
72% response rate (above 62% average).
Louise Turner
All Responded
2016-0322
7 Sep 2016
Department of Health and Social Care
Devon Partnership Trust
NHS Northern Eastern and Western Clinic…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care beds.
Harry Glibbery
All Responded
2016-wp25368
16 Aug 2016
Plymouth Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Michael Younghusband
All Responded
2016-0235
23 Jun 2016
Great Western Railway
Railway related deaths
Concerns summary
A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.
Jessica Birkhead
All Responded
2016-0208
2 Jun 2016
Eastern and Western Devon Clinical Comm…
Northern
Seaton and Colyton Medical Practice
Mental Health related deaths
Concerns summary
Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.
Keenan Walsh
All Responded
2016-0202
27 May 2016
Devon County Council
North Devon Council
Child Death (from 2015)
Concerns summary
Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.
David Curtis
All Responded
2016-0144
31 Mar 2016
Devon County Council
Road (Highways Safety) related deaths
Concerns summary
Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill crest, unlike the opposite direction which has appropriate warnings.
Patricia Medland
All Responded
2016-0102
22 Feb 2016
Bampton Surgery
Community health care and emergency services related deaths
Concerns summary
The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.
Peter Tye
All Responded
2016-0050
15 Feb 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.
Michael Valentine
All Responded
2016-0032
2 Feb 2016
Knowle House Surgery
Community health care and emergency services related deaths
Concerns summary
Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were not marked urgent nor accompanied by a phone call.
Darren Wakefield
All Responded
2016-0020
22 Jan 2016
National Police Chiefs’ Council
Police related deaths
Concerns summary
The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial safety improvements.
Diane Knight
All Responded
2015-0408
22 Oct 2015
Devon Partnership Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.
William Harnell
All Responded
2015-0384
22 Sep 2015
Department of Health and Social Care
Plymouth Hospitals NHS Trust
Social Services Truro Cornwall
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.
Cameron Laing
All Responded
2015-0268
10 Jul 2015
Ministry of Defence
Service Personnel related deaths
Concerns summary
Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.
Judith Saville
All Responded
2015-0011
15 Jan 2015
Axminster Medical Practice
Devon Partnership NHS Trust
Community health care and emergency services related deaths
Concerns summary
Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.
Jason Palmer
All Responded
2014-0534
12 Dec 2014
Devon and Cornwall Constabulary
Police related deaths
Concerns summary
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment for a shotgun licence renewal.
Polly Carpenter
All Responded
2014-0469
28 Oct 2014
Devon Partnership NHS Trust
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.
Jude Kliem
All Responded
2014-0464
29 Aug 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The coroner identified a critical breakdown in communication as a key concern.
Elaine Jobe
All Responded
2014-0350
14 Jul 2014
Devon Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.
Leslie Harding
All Responded
2014-0169
8 Apr 2014
Oak Side Surgery
Community health care and emergency services related deaths
Concerns summary
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Roger Duggan
All Responded
2014-0157
7 Apr 2014
Royal Devon and Exeter Hospital NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Luke Lyons
All Responded
2013-0203
17 Sep 2013
Devon County Council
Road (Highways Safety) related deaths
Action taken summary
Devon County Council has used media channels and distributed letters to parishes and its website to alert road users to difficult travelling conditions. They confirm ongoing monitoring of the carriage
David Hulme
All Responded
2022-0199
University Hospitals Plymouth NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis at this regional centre.
Action taken summary
University Hospitals Plymouth has approved funding for four Consultant Pathologist posts and is actively recruiting, though acknowledging national shortages may prolong the process. They have also imp