Hampshire, Portsmouth and Southampton
Coroner Area
Reports: 105
Earliest: Mar 2014
Latest: 27 Jan 2026
70% response rate (above 62% average).
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.
Haydn Burton
Partially Responded
2016-0346
4 Oct 2016
HM Prison Service
Samaritans
State Custody related deaths
Suicide (from 2015)
Concerns summary
Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.
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.
Michael Blow
Historic (No Identified Response)
2016-wp25367
12 Aug 2016
Portsmouth Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Yogalakshmi Sinnaiah
Partially Responded
2016-0264
25 Jul 2016
Hampshire County Council
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, suggesting a need for physical barriers.
Sheldon Woodford
Historic (No Identified Response)
2016-0189
16 May 2016
HMP Winchester
State Custody related deaths
Concerns summary
Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
Steven Murphy
Historic (No Identified Response)
2016-0164
27 Apr 2016
South West Trains
Mental Health related deaths
Suicide (from 2015)
Concerns summary
South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge parapet.
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.
James Robertson
Historic (No Identified Response)
2016-0053
15 Feb 2016
Healthcare Management Solutions Ltd
Care Home Health related deaths
Concerns summary
Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.
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.
Thelma Clarkson
Unknown
27 Nov 2015
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Rosalind Baird
Unknown
2 Sep 2015
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Bradley Hooper
Partially Responded
2015-0285
20 Jul 2015
M C Federation
Portsmouth Motocross Club
Other related deaths
Concerns summary
An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, and the MCF Code of Practice lacks smartphone use guidance.
Daniel Strickland
Historic (No Identified Response)
2015-0505
20 Feb 2015
St Edward’s School
Child Death (from 2015)
Other related deaths
Concerns summary
Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
Alois Piska
Partially Responded
2014-0553
23 Dec 2014
Care UK
Portsmouth City Council
Harry Sotnick House
Care Home Health related deaths
Concerns summary
The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
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.
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.
George Vickery
Historic (No Identified Response)
2014-0441
13 Oct 2014
Southern Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.
Matthew Flatman
Historic (No Identified Response)
2014-0429
6 Oct 2014
Home Office
Alcohol, drug and medication related deaths
Concerns summary
The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.
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.
George Stone
Historic (No Identified Response)
2014-0379
20 Aug 2014
National Patient Safety Agency
Community health care and emergency services related deaths
Concerns summary
National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.
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.
Arthur Shaw
Historic (No Identified Response)
2014-0593
14 May 2014
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing tests, despite potential cognitive impairment like dementia.