Essex

Coroner Area
Reports: 112 Earliest: May 2014 Latest: 4 Mar 2026

68% response rate (above 62% average).

Response Status
Responded 76 Historic 31 Pending 4
AI Classification
Action Taken 68%
Action Planned 18%
Noted 12%
Disputed 2%
Based on 56 classified responses
Top Categories
Hospital Death (Clinical Procedure… (48) Suicide (from 2015) (26) Mental Health related deaths (23) Alcohol, drug and medication relat… (14) Community health care and emergenc… (9)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: +42 reports · +2pp response rate
vs national average: +29 reports · +6pp response rate
Clear 31 results
Harold Ambrose
Historic (No Identified Response)
2015-0118 25 Mar 2015
Home Office
Other related deaths
Concerns summary There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Maria Stubbings
Historic (No Identified Response)
2014-0458 23 Oct 2014
Ministry of Justice Home Office Treasury Solicitors
Other related deaths
Concerns summary Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.
Julie Robertson
Historic (No Identified Response)
2014-0326 16 Jul 2014
Southend University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care and readiness for surgery.
Jessica Bond
Historic (No Identified Response)
2014-0297 30 Jun 2014
Southend University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Marion Turner
Historic (No Identified Response)
2014-0300 25 Jun 2014
North Essex Partnership NHS Foundation …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.
Frances Bell
Historic (No Identified Response)
2014-0299 6 Jun 2014
Southend Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.