Hertfordshire
Coroner Area
Reports: 36
Earliest: Oct 2013
Latest: 4 Sep 2025
72% response rate (above 62% average).
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
Ministry of Justice
HMP The Mount
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 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 Constabulary
Hertfordshire Partnership University NH…
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.
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.
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.
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.
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.