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
105 results
Courtney Mills
All Responded
2014-0224 12 May 2014
Portsmouth Hospitals NHS Trust Waterside Medical Centre
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.
Matthew Simmonds
Historic (No Identified Response)
2014-0119 14 Mar 2014
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
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