Essex

Coroner Area
Reports: 115 Earliest: May 2014 Latest: 18 Mar 2026

73% response rate (above 63% average).

Response Status
Responded 84 Historic 31
AI Classification
Action Taken 61%
Action Planned 24%
Noted 15%
Disputed 1%
Based on 127 classified responses
Top Categories
Hospital Death (Clinical Procedure… (51) 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: +44 reports · +5pp response rate
vs national average: +31 reports · +10pp response rate
115 results
Steven Jackson
Historic (No Identified Response)
2015-0422 2 Nov 2015
Bevan Brittan Law Firm East of England Ambulance Service NHS T… General Medical Council +3 more
Community health care and emergency services related deaths
Concerns summary (AI summary) A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.
Erich Speilmann
Historic (No Identified Response)
2015-0389 20 Oct 2015
Essex Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) The quality of street lighting at the incident location was poor and may have contributed to the event.
John Roberts
Historic (No Identified Response)
2015-0389-wp25035 28 Sep 2015
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated crossing, posing significant risk.
David Charles
Historic (No Identified Response)
2015-0366 16 Sep 2015
Essex County Council Essex Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI 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 (AI 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 (AI summary) The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
Action Planned (AI summary) First Essex Buses is investigating with Optare the feasibility of retro-fitting containment measures onto the relevant bus and is engaging with other parties to explore the issue of containment for priority seats with the aim of adopting an industry-wide approach. They note this initiative is ongoing and any unilateral action would have piecemeal effect.
John Leyin
All Responded
2014-0563 16 Dec 2014
Basildon Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Following the death, Basildon and Thurrock University Hospitals NHS Trust undertook an investigation and developed an action plan. Actions include appointing a Risk and Document Control Manager, overhauling NPSA Alert dissemination, and strengthening nasogastric tube training with designated assessors and monthly compliance reports.
Maria Stubbings
Historic (No Identified Response)
2014-0458 23 Oct 2014
Ministry of Justice Select Committee, Home Affairs Home Office +1 more
Other related deaths
Concerns summary (AI 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 (AI 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 (AI 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 (AI summary) The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was not read until after her death.
Bradley Cockel
Historic (No Identified Response)
2014-0298 9 Jun 2014
The Advisory Council on the Misuse of D…
Alcohol, drug and medication related deaths Care Home Health related deaths
Concerns summary (AI 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 (AI summary) The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Komba Kpakiwa
Partially Responded
2014-0301 23 May 2014
Chartered Institute of Environmental He… Institute of Occupational Safety and He…
Other related deaths
Concerns summary (AI 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.
Action Planned (AI summary) IOSH will raise awareness among its 44,000 members regarding the deaths of hotel swimming pool users by including a summary of the key findings in the next issue of their magazine and a news item in their e-bulletin.
Josephine Foday
All Responded
2014-0301-wp24614 23 May 2014
Chartered Institute of Environmental He…
Other related deaths
Concerns summary (AI 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.
Action Planned (AI summary) • IOSH will raise awareness among its 44,000 members by highlighting the facts of this case, the concerns raised, and the Health and Safety Executive guidance on this topic. • A summary of the key findings will be included in the next available issue (September 2014) of the Institution's official member magazine the Safety and Health Practitioner. • A news item will be included in the e-bulletin, Connect, on Monday 21 July, which is distributed to all members.