Plymouth, Torbay and South Devon

Coroner Area
Reports: 119 Earliest: Sep 2013 Latest: 9 Mar 2026

72% response rate (above 62% average).

Response Status
Responded 86 No Response 1 Historic 21 Pending 4
AI Classification
Action Taken 56%
Action Planned 38%
Noted 0%
Disputed 6%
Based on 32 classified responses
Top Categories
Hospital Death (Clinical Procedure… (57) Suicide (from 2015) (16) Mental Health related deaths (12) Community health care and emergenc… (10) Alcohol, drug and medication relat… (10)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: +38 reports · +8pp response rate
vs national average: +36 reports · +10pp response rate
119 results
Roy Millar
Unknown
13 Sep 2016
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Neurology Ward Administrators were unaware of their responsibility to book follow-up appointments, resulting in a systemic failure to schedule critical post-discharge care for many patients.
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
Saleh Al-Awlaki
Partially Responded
2016-wp25366 15 Aug 2016
Highways Department Torbay Council
Road (Highways Safety) 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.
Thomas Burchell
Partially Responded
2016-0002 4 Jan 2016
Hospital NHS Trust Derriford Hospital Borchardt Medical Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
William Maskell
Unknown
14 Dec 2015
Alcohol, drug and medication related deaths
Concerns summary The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, risking future deaths.
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.
Ian Emsley
Unknown
8 Sep 2015
State Custody related deaths
Concerns summary Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Barry Pike
Unknown
19 Aug 2015
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Gordon Atkinson
Historic (No Identified Response)
2015-0311 7 Aug 2015
Plymouth City Council
Other related deaths
Concerns summary Concerns included unsuitable living accommodation, evident self-neglect, and an inappropriate care package for the deceased, indicating systemic failures in supporting his welfare.
Carl Smith
Partially Responded
2015-0298 24 Jul 2015
Dorset Health Care University NHS Found… HMP Exeter
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
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.
Alec Mathias
Historic (No Identified Response)
2015-0247 26 Jun 2015
Royal Devon and Exeter Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.
Andrew Nickolls
Historic (No Identified Response)
2015-0230 17 Jun 2015
Plymouth City Council Torbay Council Devon County Council +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.
Hayden Norton
Partially Responded
2015-0137 13 Apr 2015
Dorset Healthcare University NHS Founda… NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an emergency protocol.
Robert Jones
Partially Responded
2015-0018 21 Jan 2015
South Molton Health Care Centre South Molton Community Hospital North Devon Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per NICE guidelines.