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
Stephen Mayoll
All Responded
2014-0515 25 Nov 2014
Portsmouth Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Tessa Summers
All Responded
2014-0383 22 Aug 2014
Hampshire County Council
Community health care and emergency services related deaths
Concerns summary Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked sufficient training and support for Shared Lives Carers assisting clients with mental health issues.
Charles Lawrence
All Responded
2014-0342 25 Jul 2014
Alexandra Rose Care Home
Care Home Health related deaths
Concerns summary The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Courtney Mills
All Responded
2014-0224 12 May 2014
Waterside Medical Centre Portsmouth Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Kathleen Border
All Responded
2014-0095 4 Mar 2014
Northwood Square
Other related deaths
Concerns summary Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Marco Lima De Araujo
All Responded
2014-0093 3 Mar 2014
Queen’s Harbour Master Portsmouth
Other related deaths
Concerns summary There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Alun Davies
All Responded
2022-0196
South Western Railway and BTP Fatal Inv…
Mental Health related deaths Railway related deaths Suicide (from 2015)
Concerns summary Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public welfare announcements are lacking.
Action taken summary South Western Railway has rejected increasing staffing levels, RCO patrols, and 24/7 CCTV surveillance at Portchester Station, stating existing measures are adequate. They have already installed tresp