Hertfordshire
Coroner Area
Reports: 36
Earliest: Oct 2013
Latest: 4 Sep 2025
72% response rate (above 62% average).
Kevin Hefferman
All Responded
2016-0381
25 Oct 2016
Highways England
Road (Highways Safety) related deaths
Concerns 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.
Vichal Tonpradit
All Responded
2016-0380
11 Oct 2016
Highways England
Road (Highways Safety) related deaths
Concerns summary
A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal injuries.
Jan Bodnar
All Responded
2016-0166
29 Apr 2016
Hertfordshire County Council
Road (Highways Safety) related deaths
Concerns summary
Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.
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
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.
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
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.
Simon Satchwell
Historic (No Identified Response)
2014-0537
12 Dec 2014
Foreign, Commonwealth & Development Off…
Other related deaths
Concerns 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
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.
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
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
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
John Gwynfryn Morris
All Responded
2013-0295
11 Nov 2013
Care Quality Commission
Care Home Health related deaths
Concerns 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 taken summary
The CQC acknowledges concerns about dementia care staffing and underestimation of needs, clarifying their existing inspection methods. They plan to publish a thematic report on good practice in dement
Ishmail Kubilay
Historic (No Identified Response)
2013-0248
3 Oct 2013
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.