Essex
Coroner Area
Reports: 115
Earliest: May 2014
Latest: 18 Mar 2026
73% response rate (above 63% average).
June Parlour
All Responded
2020-0186
28 Sep 2020
East Suffolk and North Essex NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.
Action Taken
(AI summary)
ESNEFT updated the Morphine and Naloxone Administration Guidelines, communicated them to staff, and published them on the Trust intranet and Medusa app. They also developed a new Morphine Prescription sticker and updated the Morphine Administration Competency Framework.
Zak Farmer
All Responded
2020-0196
24 Sep 2020
Essex Partnership University NHS Founda…
Castle Rock Group
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Action Planned
(AI summary)
CRG Medical states a member of the mental health team attends all MHA s117 meetings and they now have a dual system for patient records, audited weekly. They provide advice on registering with a community GP and provide a discharge summary that is now accessible to GPs through NHS Spine. They also employ a social inclusion representative to assist with discharge arrangements. EPUT states that the Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment plan is currently under review to ensure it is comprehensive and provides clear guidance for staff.
Frederick Terry
All Responded
2020-0173
9 Sep 2020
Mid and South Essex NHS Foundation Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.
Action Taken
(AI summary)
Mid and South Essex Foundation Trust has strengthened processes, implemented a locum checklist, and added a self-assessment tool for obstetric skills. They employed an additional Obstetric Consultant, implemented a 24-hour bleep for the Senior Nurse in the Neonatal unit, and are driving the 'Below Ten Thousand Feet' initiative for communication in theatres.
Luiz Anjos
All Responded
2020-0259
13 Jul 2020
Highways Agency Essex County Council
Mental Health related deaths
Railway related deaths
Concerns summary (AI summary)
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Action Planned
(AI summary)
Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.
Malika Shamas and Haider Ali
Historic (No Identified Response)
2020-0034
18 Feb 2020
Tendering District Council
Other related deaths
Concerns summary (AI summary)
Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need for improved information boards and increased beach patrol presence.
Joseph Gingell
All Responded
2020-0027
17 Feb 2020
NHS England
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Noted
(AI summary)
NHS England acknowledges concerns about drug toxicity, self-certification, and not informing GPs but states the death appears to be from services outside the NHS, restating commitment to improving the safety of controlled drugs and online prescribing, highlighting existing guidelines and initiatives.
Joanna Flynn
Partially Responded
2019-0369
14 Nov 2019
Department of Health and Social Care
Fern House Surgery
Mid Essex Clinical Commissioning Group …
+1 more
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.
Noted
(AI summary)
NHS England/Improvement acknowledges the need for national-level guidance and support, highlighting a review group established in response to the PHE review. They note the complexity of patients with addiction to prescribed medications and the need for multidisciplinary input. The Department of Health and Social Care highlights the PHE report on prescription drug dependence and the review of overprescribing led by Dr Keith Ridge. The Mid-Essex CCG will implement a Management of Prescribed Opioid Dependence Locally Enhanced Service from April 2020. Mid Essex CCG details plans for a Local Enhanced Service for substance misuse, joint guidance for de-prescribing, and a session on Opioids and Safe Prescribing at the CCG's Time to Learn event in March.
Raymond Knight
Historic (No Identified Response)
2019-0120
5 Apr 2019
Essex Police
Police related deaths
Concerns summary (AI summary)
Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.
Kelly Campbell
Historic (No Identified Response)
2018-0271
9 Aug 2018
Essex Partnership University NHS Founda…
Mental Health related deaths
Concerns summary (AI summary)
Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating physical environment in patient rooms, which contributes to boredom.
Timothy Shaw
Partially Responded
2018-0047
15 Feb 2018
Care UK Clinical Services
Essex Partnership University NHS Founda…
Farleys Solicitors LLP
+2 more
State Custody related deaths
Concerns summary (AI summary)
Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Noted
(AI summary)
Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
David Green
Historic (No Identified Response)
2018-0027
1 Feb 2018
Rose Builders and Contractors Ltd
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing seatbelts, with inadequate systems to check compliance.
Craig Royce
Partially Responded
2017-0379
20 Dec 2017
Bindmans Solicitors
Care UK
Essex Partnership NHS Trust
+2 more
Hospital Death (Clinical Procedures and medical management) related deaths
State Custody related deaths
Concerns summary (AI summary)
A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.
Action Taken
(AI summary)
Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.
David Lindsey
Historic (No Identified Response)
2017-0213
14 Sep 2017
Basildon and Thurrock University Hospit…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Terence Pimm
All Responded
2017-0217
14 Aug 2017
Essex Partnership University NHS Founda…
Essex Community Rehabilitation Company
Essex Police
Police related deaths
Concerns summary (AI summary)
Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Action Taken
(AI summary)
The Trust has directed all health-based place of safety calls through a new call centre where calls are recorded and documented. They have also reinforced to staff the importance of family involvement, reinforced the information-sharing concordat, launched a new street-triage team, and put a new flowchart in place for staff detailing actions to take when people are subject to a warrant, with training underway. Essex Police have instructed switchboard operators to refer public calls not concerning a person in custody to the Force Control Room, and advised custody suite staff on handling detainee-related calls. FCR staff receive training on threat, harm, and risk assessment. The police are implementing a process to notify Essex Police when staff meet with wanted persons and are developing Information Sharing Agreements with health partners.
Roy Lynch
Historic (No Identified Response)
2017-0431
5 Jul 2017
Essex Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers encountering stationary vehicles at speed.
Dean Saunders
Partially Responded
2017-0056
17 Feb 2017
Care UK Clinical Services
National Offender Management Service
NHS England
+1 more
Community health care and emergency services related deaths
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Action Planned
(AI summary)
NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at HMP Chelmsford from May 2017 with greater access to psychiatrists. Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; it has also referred the issue of best practice in relation to the forensic pathway to the same group. Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to examine processes and quality of care provided.
Melanie Lowe
All Responded
2016-0404
11 Nov 2016
North Essex University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.
Action Taken
(AI summary)
The Trust updated its action plan with supporting evidence and will complete a further audit to ensure that all the actions identified have been embedded into practice.
Martha Davies
Historic (No Identified Response)
2016-0331
16 Sep 2016
Anglian Community Enterprise
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.
Warren Sampson
Partially Responded
2016-0320
6 Sep 2016
Care UK
Family Solicitors
HMP
State Custody related deaths
Concerns summary (AI summary)
Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Action Taken
(AI summary)
Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health Screen is undertaken within 72 hours of an inmate arriving to ensure matters such as consent for obtaining GP records has been sought.
Margaret Richardson
Historic (No Identified Response)
2016-wp25380
19 Aug 2016
North Essex Mental Health Partnership T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Jonathan Weatherley
Historic (No Identified Response)
2016-0206
2 Jun 2016
Trading Standards
Product related deaths
Concerns summary (AI summary)
Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a comprehensive, widely distributed new recall.
Keith Harper
All Responded
2016-0151
21 Apr 2016
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by resurfacing and debris.
Action Taken
(AI summary)
Essex County Council has completed work to refresh the carriageway markings exiting the roundabout, including the segregation line and give-way triangles.
Roy Oakley
Historic (No Identified Response)
2016-0126
1 Apr 2016
Basildon Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text.
Dorota Kijowska
Historic (No Identified Response)
2016-0121
29 Mar 2016
North Essex Partnership University NHS …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.
David Pooley
Partially Responded
2015-0421
3 Nov 2015
South Essex Mental Health Partnership T…
Lancashire Care NHS Trust
Mental Health related deaths
Concerns summary (AI summary)
A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.
Action Planned
(AI summary)
• All staff have been briefed on the referral process, and learning from the joint investigation has been shared.
• The Trust is exploring using the CRISP board in the Emergency Department to record referrals to specialist teams.
• The Trust is exploring the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief.