Hampshire, Portsmouth and Southampton

Coroner Area
Reports: 105 Earliest: Mar 2014 Latest: 27 Jan 2026

70% response rate (above 62% average).

Response Status
Responded 73 No Response 2 Historic 26 Pending 1
AI Classification
Action Taken 39%
Action Planned 29%
Noted 24%
Disputed 8%
Based on 38 classified responses
Top Categories
Hospital Death (Clinical Procedure… (29) Suicide (from 2015) (21) Other related deaths (14) Alcohol, drug and medication relat… (13) Mental Health related deaths (11)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: +24 reports · +10pp response rate
vs national average: +22 reports · +8pp response rate
Clear 57 results
Seth Thind
All Responded
2022-0323 17 Oct 2022
Highways England Hampshire Highways
Suicide (from 2015)
Concerns summary A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.
Robert Taylor
All Responded
2022-0281 8 Sep 2022
University Hospital Southampton NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with epistaxis or facial fractures, potentially missing continued bleeding.
Barbara Proudlove
All Responded
2022-0210 12 Jul 2022
Berkeley Home Health
Care Home Health related deaths
Concerns summary The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and skills in recognizing and responding to medical emergencies.
Beatrice Dawkins
All Responded
2022-0099 5 Apr 2022
Portsmouth Hospitals NHS Trust
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.
Nicholas O’Brien
All Responded
2021-0197 9 Jun 2021
British Kite Surfing Association
Other related deaths Product related deaths
Concerns summary A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment method was insecure, posing risks for similar helmet-mounted accessories.
Kesia Waller
All Responded
2021-0187 1 Jun 2021
A2Dominion of The Point
Care Home Health related deaths Child Death (from 2015) Suicide (from 2015)
Concerns summary Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.
Callum Evans
All Responded
2021-0159 18 May 2021
Network Rail
Alcohol, drug and medication related deaths Railway related deaths
Concerns summary A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and life-threatening danger.
Andrew Biddlecombe
All Responded
2021-0053 25 Feb 2021
Emsworth Surgery
Community health care and emergency services related deaths Road (Highways Safety) related deaths
Concerns summary The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.
Arthur Johnson
All Responded
2021-0003 5 Jan 2021
Hampshire County Council and Oakridge H…
Care Home Health related deaths
Concerns summary Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
Robert Goodman
All Responded
2020-0285 15 Dec 2020
University Hospital Southampton NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, leading to delayed diagnosis.
Sophie Boothe
All Responded
2020-0142 2 Mar 2020
Berkshire Healthcare NHS Foundation Tru…
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Nigel Malloy
All Responded
2018-0232 19 Jul 2018
South Staffordshire & Shropshire NHS Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.
Joan Betteridge
All Responded
2018-0026 26 Jan 2018
Hampshire NHS Trust Park & Francis Surgery
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.
Ronald Jones
All Responded
2017-0416 23 Nov 2017
Portsmouth City Council
Other related deaths
Concerns summary Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.
Timothy Atkins
All Responded
2017-0265 9 Nov 2017
Portsmouth City Council
Road (Highways Safety) related deaths
Concerns summary A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.
Gordon Penistan
All Responded
2017-0313 31 Oct 2017
Adult Social Services
Community health care and emergency services related deaths
Concerns summary Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.
Sean Plumstead
All Responded
2017-0316 9 Aug 2017
Carillion HM Prison and Probation Services
State Custody related deaths
Concerns summary Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Grant Burns
All Responded
2017-0048 23 Feb 2017
Solent NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.
Dennis Lavington
All Responded
2016-0443 12 Dec 2016
Solent NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe paths from parking to the entrance.
Christopher MacMorland
All Responded
2016-0415 16 Nov 2016
Portsmouth Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing consultant-recommended patient transfers.
Samantha Hopkins
All Responded
2016-0316 6 Sep 2016
South Central Ambulance Service Warwick Medical School
Community health care and emergency services related deaths Product related deaths
Concerns summary Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Anna Masson
All Responded
2016-0108 15 Mar 2016
Southern Health NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths Railway related deaths
Concerns summary A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
James Barrett
All Responded
2016-0052 15 Feb 2016
Hampshire Constabulary Police
Other related deaths
Concerns summary Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for searchers.
Louise Locke
All Responded
2016-0026 29 Jan 2016
Southern Health NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.
Garry Gilbey
All Responded
2014-0533 10 Dec 2014
Ministry of Justice Department of Health and Social Care
State Custody related deaths
Concerns summary The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.