Isle of Wight

Coroner Area
Reports: 19 Earliest: Apr 2014 Latest: 8 Mar 2021

47% response rate (below 63% average).

Response Status
Responded 9 Historic 10
AI Classification
Action Taken 18%
Action Planned 73%
Noted 0%
Disputed 9%
Based on 11 classified responses
Top Categories
Hospital Death (Clinical Procedure… (9) Road (Highways Safety) related dea… (5) Other related deaths (3) Alcohol, drug and medication relat… (2) Mental Health related deaths (2)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: -63 reports · -13pp response rate
vs national average: -65 reports · -16pp response rate
19 results
Yvonne Copland
All Responded
2021-0067 8 Mar 2021
Highways – Isle of Wight Council and Ri…
Other related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate signage/safety measures, despite being a high-traffic route.
Action Planned (AI summary) The Isle of Wight Council will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction. Ringway Island Roads will commission junction designs in May 2021, conduct a design review and consultation in July 2021, commit to a design option in September 2021, tender for a delivery contractor in November 2021, and commence works in February 2022 to improve the junction.
Annette Lewis
Partially Responded
2020-0004 13 Jan 2020
Suicide Prevention Group, Isle of Wight… National Trust for the Isle of Wight Public Health for the Isle of Wight
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting suicide at this and similar sites.
Action Planned (AI summary) The Isle of Wight National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, IOW Samaritans, and the Police to review and improve suicide prevention measures on their land. A full internal review of suicide prevention measures will be conducted after the meetings are complete.
Joanna Orpin
All Responded
2019-0457 31 Dec 2019
Isle of Wight Council National Trust on the Isle of Wight
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.
Action Planned (AI summary) The National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, and the IOW Samaritans to discuss suicide prevention on their land. They will conduct an internal review of suicide prevention measures after these meetings.
Nathan Cooke
Historic (No Identified Response)
2019-0125 17 Apr 2019
Hampshire and Isle of Wight Clinical Co…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Megan Jones
Historic (No Identified Response)
2019-0126 17 Apr 2019
Hampshire and Isle of Wight Clinical Co…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Wayne Rodgers
Partially Responded
2019-0105 28 Mar 2019
Cowes Week Limited Emergency Preparedness, Resilience and … Resilience and Response, Isle of Wight … +2 more
Emergency services related deaths (2019 onwards) Other related deaths
Concerns summary (AI summary) Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment requirements and racing abandonment criteria.
Action Planned (AI summary) Cowes Week Limited is discussing additional ambulance support, reviewing AED placement, reinforcing the necessity of having a sharp knife on board, and reviewing criteria for abandoning racing. The organisation will have independent radio operators to monitor safety communications and will address continuous spinnaker sheets in their safety booklet.
Natalie Hunter
Historic (No Identified Response)
2018-0392 18 Dec 2018
St Mary’s Hospital NHS Trust
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.
Jacqueline Valvona
All Responded
2018-0391 18 Dec 2018
Island Roads Isle of Wight Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A lack of safe pedestrian crossing on a busy road near a popular pub, especially for elderly residents with mobility issues, may lead to future deaths.
Action Planned (AI summary) Island Roads will undertake a further pedestrian survey in the summer months to determine vehicle and pedestrian numbers during peak tourist season, and then assess the suitability of a new controlled crossing. The Isle of Wight Council instructed Island Roads to undertake a feasibility study and design for a pedestrian controlled crossing and will undertake a further assessment in the summer to determine whether a new crossing should be considered.
Cuthbert Hingert
Historic (No Identified Response)
2018-0280 1 Aug 2018
Isle of Wight NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.
Lee Daniel
All Responded
12 Jan 2018
Isle of Wight Council Highways Departme…
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers onto the wrong side of the road and increasing accident risk.
1 response from Lee Daniel
Joseph Dune
Historic (No Identified Response)
2017-0371 12 Dec 2017
Care Quality Commission Isle of Wight NHS Trust St Mary’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.
Ann Hardman
All Responded
2016-0350 10 Oct 2016
Isle of Wight NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department is needed to improve compliance.
Action Taken (AI summary) The Isle of Wight NHS Trust now books a repeat ultrasound scan for patients with a D-Dimer positive blood result but a negative initial scan, and will inform the GP if the patient doesn't attend. A joint letter with a GP has been sent to all Island GPs to inform them of this new procedure.
Stephen St Clair
Historic (No Identified Response)
2016-wp25358 12 Aug 2016
Ministry of Justice National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.
Jonathan Hawes
All Responded
2015-0466 24 Nov 2015
Islands Roads
Road (Highways Safety) related deaths
Concerns summary (AI summary) The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is a critical need to reconsider the speed limit and install appropriate road signage.
Disputed (AI summary) Island Roads argues that existing signage is adequate and the collision record doesn't indicate excessive speed, so a reduced speed limit is unlikely to have a measurable impact. The police do not support a reduced speed limit.
John Darling
Historic (No Identified Response)
2015-0037 3 Feb 2015
Isle of Wight Council Off the Rails Cafe Owner of the "Off The Rails Café" site
Other related deaths
Concerns summary (AI summary) An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.
Lara Mamula
Historic (No Identified Response)
2014-0508 24 Nov 2014
Isle of Wight Ambulance Service Isle of Wight NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.
Barbara Cooke
Historic (No Identified Response)
2014-0405 12 Sep 2014
Care Quality Commission Isle of Wight Adult Safeguarding Team St Mary’s Hospital +1 more
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
John Day
All Responded
2014-0251 4 Jun 2014
Beacon Healthcare Isle of Wight Clinical Commissioning Gr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.
Action Planned (AI summary) The Isle of Wight CCG is developing a system-wide IT strategy to move towards a universal, integrated, and readily accessible healthcare record, but notes there is still a long way to go. A reminder was sent to all out of hours GPs to consider trying to access Vision 360 if clinically indicated, and the Beacon out of hours service is working closely with primary care, the ambulance service and secondary care. The Adastra system has been integrated into the overarching hospital system ISIS.
William Watson
Historic (No Identified Response)
2014-0146 2 Apr 2014
Hampshire Constabulary Island Roads Isle of Wight Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety hazard.