Hertfordshire

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

72% response rate (above 63% average).

Response Status
Responded 26 Historic 10
AI Classification
Action Taken 34%
Action Planned 55%
Noted 11%
Disputed 0%
Based on 38 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: -35 reports · +4pp response rate
vs national average: -48 reports · +9pp response rate
36 results
Kevin Hefferman
All Responded
2016-0381 25 Oct 2016
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an ongoing danger to road users, especially during heavy rain.
Action Planned (AI summary) National Highways has undertaken an initial investigation of the carriageway section and will conduct a further review of the design considerations made during the major improvement scheme. The review is due to be completed in the spring of 2017.
Vichal Tonpradit
All Responded
2016-0380 11 Oct 2016
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal injuries.
Action Taken (AI summary) National Highways obscured a redundant road marking with bituminous material. A Smart Motorway scheme is planned for 2020 that will alter the road layout.
Jan Bodnar
All Responded
2016-0166 29 Apr 2016
Hertfordshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.
Action Taken (AI summary) The Council cleared vegetation at a specific junction in July 2015. They also carried out an assessment of similar junctions, identifying 6 requiring vegetation clearance, which is planned for July 2016. The Council also revised the remit for highway safety inspectors and revised the maintenance regime for vegetation for the identified length of road.
Rebecca Jones
All Responded
2015-0504 8 Oct 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Action Planned (AI summary) NHS England will spend £15m in 2016/17 to boost provision in areas that lack adequate health-based places of safety and is developing commissioning guidance for effective crisis response. HEE is undertaking a root and branch review of its workforce development spend.
Eileen Smith
All Responded
2015-0500 12 Aug 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Noted (AI summary) The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by the Department of Health.
Simon Satchwell
Historic (No Identified Response)
2014-0537 12 Dec 2014
Foreign, Commonwealth & Development Off…
Other related deaths
Concerns summary (AI summary) Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult supervision, differing from UK safety standards.
Stephen Amer
All Responded
2014-0344 25 Jul 2014
Hertfordshire County Council
Community health care and emergency services related deaths
Concerns summary (AI summary) Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and the broader family's well-being, particularly for those under significant stress.
Action Planned (AI summary) Hertfordshire County Council will develop and introduce a consent form by 20 October 2014 to allow patient information to be shared with social care services. The department has issued a practice instruction to social care staff to create or update a separate carer's assessment and will share the conclusions with local hospital trusts in an effort to ensure that they allow sufficient time to discuss discharges with relatives / carers face to face.
Yahya Khan
Historic (No Identified Response)
2014-0334 22 Jul 2014
National Institute of Health and Care E…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced clinicians assess rare conditions.
Ozan Atasoy
All Responded
2014-0166 9 Apr 2014
Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
Action Planned (AI summary) CQC will disseminate the coroner's report within the CQC, particularly in relation to inspections of hospitals, and feed the issues into intelligent monitoring systems and key lines of enquiry. They will also consider improvements that have been implemented by the trust.
John Gwynfryn Morris
All Responded
2013-0295 11 Nov 2013
Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary) Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous escape incidents.
Action Planned (AI summary) The CQC acknowledges concerns about care for people living with dementia and states that they are proposing to publish a report in May or June 2014 which will set out good practice and make recommendations about dementia care across different services.
Ishmail Kubilay
Historic (No Identified Response)
2013-0248 3 Oct 2013
Department of Health and Social Care Ministry of Justice
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.