Hertfordshire

Coroner Area
Reports: 36 Earliest: Oct 2013 Latest: 4 Sep 2025

72% response rate (above 62% average).

Response Status
Responded 26 Historic 10
AI Classification
Action Taken 58%
Action Planned 17%
Noted 8%
Disputed 17%
Based on 12 classified responses
Top Categories
Hospital Death (Clinical Procedure… (13) Suicide (from 2015) (6) Road (Highways Safety) related dea… (6) Other related deaths (5) Alcohol, drug and medication relat… (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: -34 reports · +6pp response rate
vs national average: -47 reports · +10pp response rate
36 results
Cheryl Edwards
All Responded
2025-0449 4 Sep 2025
Chief Executive Hertfordshire County Co…
Road (Highways Safety) related deaths
Concerns summary The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.
Action taken summary The Road Policing Unit, through its Traffic Management Officers, disputes the need to reduce the 60mph speed limit on Sarratt Road. They state the limit is consistent with speed management …
Darren Reilly
All Responded
2025-0362 18 Jul 2025
National Highways Agency
Road (Highways Safety) related deaths
Concerns summary An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control and leave the carriageway at high speed.
Action taken summary Nottinghamshire Police has conducted demand pattern analysis of mental health incidents and s.136 detentions. Based on this, they are exploring extending the hours of the Street Triage Team until 03:0
Paul Burke
All Responded
2025-0215 2 May 2025
Department of Health and Social Care
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose a risk of future deaths.
Action taken summary The DHSC will publish its 10-Year Health Plan in Summer 2025 and has set new headline ambitions for the NHS, including reducing ambulance handover times and A&E waits. They are …
Joshua Weavers
All Responded
2025-0187 17 Feb 2025
NHS England Hertfordshire County Council Hertfordshire & West Essex Integrated C…
Child Death (from 2015) Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.
Action taken summary Hertfordshire and West Essex ICB has provided significant investment to transform neurodevelopmental pathways, enabling the implementation of a new ADHD assessment model and a single point of access a
Megan Davison
All Responded
2024-0373 15 Jul 2024
Department of Health and Social Care Hertfordshire and West Essex Integrated…
Suicide (from 2015)
Concerns summary A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient records with private providers, impedes comprehensive care.
Action taken summary Hertfordshire and West Essex ICB has an integrated T1DE clinical pathway in the west of the county and a similar service commissioned for the east and north, working towards full …
Susan Gladstone
Historic (No Identified Response)
2023-0485 20 Nov 2023
REDACTED
Alcohol, drug and medication related deaths
Concerns summary A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously high INR levels.
Kristopher Tilbury
Historic (No Identified Response)
2023-0331Deceased 8 Sep 2023
HMP The Mount Ministry of Justice
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
David Andrews
All Responded
2023-0329 1 Aug 2023
Hertfordshire County Council
Road (Highways Safety) related deaths
Concerns summary Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound carriageway and creating a hazard.
David Clark
Historic (No Identified Response)
2022-0046 15 Feb 2022
East & North Hertfordshire NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.
John Skinner
Historic (No Identified Response)
2022-0041 10 Feb 2022
NHS England
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Daphne Holloway and Ivy Spriggs
Historic (No Identified Response)
2022-0043 10 Feb 2022
Communities & Local Government Ministry of Housing
Care Home Health related deaths
Concerns summary Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant vulnerability, leaving them at elevated fire risk.
Katie Locke
Historic (No Identified Response)
2021-0222 29 Jun 2021
National Probation Service Hertfordshire Partnership University NH… Hertfordshire Constabulary
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths Police related deaths
Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.
Eddie Coffey
All Responded
2020-0287 15 Dec 2020
Department of Health and Social Care East and North Hertfordshire NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training and the use of incorrect guidelines in maternity units.
Kelly Sutton
All Responded
2020-0076 24 Mar 2020
Hertfordshire Constabulary
Other related deaths Suicide (from 2015)
Concerns summary Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding of potential victims.
Peter Cole
All Responded
2020-0123 28 Feb 2020
NHS England
Alcohol, drug and medication related deaths Other related deaths
Concerns summary Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Jack Postle
All Responded
2020-0044 26 Feb 2020
Watford General Hospital
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.
Tillie Spencer-Adams
All Responded
2019-0356 5 Sep 2019
East and North Hertfordshire NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.
Thomas Nicol
All Responded
2018-0375 30 Nov 2018
MOJ NHS England
State Custody related deaths Suicide (from 2015)
Concerns summary Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
Kevin Sherwood
All Responded
2018-0289 11 Sep 2018
Network Rail
Railway related deaths Suicide (from 2015)
Concerns summary Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Darren Urquhart
Historic (No Identified Response)
2018-0291 10 Sep 2018
Network Rail
Railway related deaths
Concerns summary Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from track access.
Daniel O’Mahony
All Responded
2018-0258 30 Aug 2018
London North Western Railways
Railway related deaths Suicide (from 2015)
Concerns summary Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
Matthew Faulkner
All Responded
2018-0097 29 Mar 2018
East of England Ambulance Service Luton and Dunstable Hospital Princess Alexander Hospital
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.
Scott Rayner
All Responded
2017-0345 20 Dec 2017
Network Rail
Railway related deaths
Concerns summary Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both adults and children.
Linda Baranowski
Partially Responded
2017-0341 22 Jul 2017
Food Standard Agency Hertfordshire Trading Standards National Food Crime Unit
Other related deaths Product related deaths
Concerns summary Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.
Brian Mills
All Responded
2016-0416 17 Nov 2016
East of England Ambulance Service
Community health care and emergency services related deaths
Concerns summary Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.