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 27 results
Margaret Taylor
All Responded
2025-0420 12 Aug 2025
Oak Tree Mews Care Home
Care Home Health related deaths
Concerns summary A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Action taken summary Oak Tree Mews Care Home has implemented several changes, including appointing a new manager, ensuring comprehensive nutritional pre-assessments, regularly updating care plans with SALT information, an
James Sheppard
All Responded
2025-0229 8 May 2025
Gloucestershire Health & Care NHS Found… Department of Health and Social Care
Suicide (from 2015)
Concerns summary There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Action taken summary The Trust has already undertaken significant work to improve bed management efficiency, reducing Out of Area Placements. They are also focused on reducing the average length of stay and are …
Maria Simpson
All Responded
2025-0011 9 Jan 2025
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.
Action taken summary The DHSC states NHS England published the GP IT Futures Operating Model in 2020. Locally, Gloucestershire ICB implemented an Obstetrics ‘Advice and Guidance’ service and changed referral pathways in D
Thomas Kingston
All Responded
2025-0007 7 Jan 2025
National Institute for Health and Care … Royal College of General Practitioners Medicines and Healthcare Products Regul…
Suicide (from 2015)
Concerns summary There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Action taken summary NICE is collaborating with the MHRA to address concerns regarding SSRI suicide risks and guidance. The outcome of this joint work will inform any necessary updates to NICE's recommendations, with …
Severine Kelly
All Responded
2024-0098 21 Feb 2024
Gloucestershire Health and Care NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.
Donald Brown
All Responded
2023-0037Deceased 31 Jan 2023
Gloucestershire Hospital NHS Foundation…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.
Richard Sanders
All Responded
2022-0003 5 Jan 2022
British Diving Safety Group National Diving and Activity Centre University Hospitals Sussex NHS Foundat…
Other related deaths
Concerns summary There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.
Elisa Fuller
All Responded
2019-0481 17 Oct 2019
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.
Colin Cameron
All Responded
2019-0218 26 Jun 2019
Network Rail
Railway related deaths
Concerns summary Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
Ahmed Motala
All Responded
2019-0168 25 May 2019
Gloucestershire County Council Highways…
Road (Highways Safety) related deaths
Concerns summary The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.
Ray Westlake
All Responded
2019-0170 24 May 2019
Gloucestershire County Council
Road (Highways Safety) related deaths
Concerns summary A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.
Barry Clow
All Responded
2019-0170-wp26665 24 May 2019
Gloucestershire County Council
Road (Highways Safety) related deaths
Christopher Barnes
All Responded
2019-0164 20 May 2019
Driver Vehicle Standards Agency Road Haulage Association
Road (Highways Safety) related deaths
Concerns summary There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.
John Alliston
All Responded
2019-0153 9 May 2019
Communities and Local Government Department for Housing
Other related deaths
Concerns summary The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.
Graham Jones
All Responded
2019-0131A 18 Apr 2019
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.
Jonathan Yates
All Responded
2019-0132A 16 Apr 2019
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.
Robert Hughes
All Responded
2019-0042 11 Feb 2019
2gether NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.
Robert Power
All Responded
2018-0221 9 Jul 2018
North Bristol NHS Trust
Care Home Health related deaths
Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Jonathan Earp
All Responded
2018-0135 8 May 2018
Gloucestershire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
David Sketchley
All Responded
2018-0069 9 Mar 2018
BUPA UK
Care Home Health related deaths
Concerns summary The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Ronald Brewer
All Responded
2017-0306 19 Oct 2017
Barchester Homes
Care Home Health related deaths
Concerns summary Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Rose Workman
All Responded
2017-0435 6 Jul 2017
Gloucestershire Care Services NHS Trust
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Terence White
All Responded
2017-0078 16 Mar 2017
Grange Care Centre
Care Home Health related deaths
Concerns summary The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.
Daphne Cherry
All Responded
2017-0080 13 Mar 2017
Care UK
Care Home Health related deaths
Concerns summary Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.
Matthew Gunn
All Responded
2016-0217 9 Jun 2016
W M Morrisons PLC
Accident at Work and Health and Safety related deaths
Concerns summary An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.