Essex
Coroner Area
Reports: 112
Earliest: May 2014
Latest: 4 Mar 2026
68% response rate (above 62% average).
David Charles
Historic (No Identified Response)
2015-0366
16 Sep 2015
Essex Highways Agency
Road (Highways Safety) related deaths
Concerns summary
Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being unable to avoid it.
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.
Percy Gurton
All Responded
2014-0546
22 Dec 2014
First Essex Buses
Other related deaths
Concerns summary
The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
John Leyin
All Responded
2014-0563
16 Dec 2014
Basildon Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, and knowledge of trained staff numbers for critical procedures was lacking.
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.
Bradley Cockel
Unknown
2014-0298
9 Jun 2014
Alcohol, drug and medication related deaths
Care Home Health related deaths
Concerns summary
The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public health risks.
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.
Josephine Foday
All Responded
2014-0301
23 May 2014
Chartered Institute of Environmental He…
Other related deaths
Concerns summary
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.
Komba Kpakiwa
Partially Responded
2014-0301-wp24615
23 May 2014
Chartered Institute of Environmental He…
Institute of Occupational Safety and He…
Other related deaths
Concerns summary
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.