Gloucestershire

Coroner Area
Reports: 41 Earliest: Aug 2013 Latest: 12 Aug 2025

78% response rate (above 62% average).

Response Status
Responded 32 No Response 1 Historic 7
AI Classification
Action Taken 60%
Action Planned 20%
Noted 20%
Disputed 0%
Based on 10 classified responses
Top Categories
Hospital Death (Clinical Procedure… (14) Care Home Health related deaths (8) Road (Highways Safety) related dea… (5) Community health care and emergenc… (5) Suicide (from 2015) (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: -40 reports · +14pp response rate
vs national average: -42 reports · +16pp response rate
Clear 7 results
Andrea Franzosi
Historic (No Identified Response)
2018-0314 25 Oct 2018
Gloucestershire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.
Martin Tilley
Historic (No Identified Response)
2018-0071 12 Mar 2018
Gloucestershire Care Services NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.
Barbara Ellis
Historic (No Identified Response)
2018-0038 2 Feb 2018
Gloucestershire Clinical Group Herefordshire Clinical Commission Group
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.
Susan Smalley
Historic (No Identified Response)
2017-0409 22 Nov 2017
Gloucestershire NHS Trust South Western Ambulance Service NHS Tru…
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.
Steven Amos
Historic (No Identified Response)
2017-0117 6 Apr 2017
Gloucestershire Hospitals NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.
Anielka Jennings
Historic (No Identified Response)
2016-0236 27 Jun 2016
Gloucestershire Clinical Commissioning … Gloucestershire County Council
Child Death (from 2015) Mental Health related deaths Suicide (from 2015)
Concerns summary No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.
Samantha Beach
Historic (No Identified Response)
2015-0413 21 Oct 2015
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.