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
Clear 7 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.
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.
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.
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
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.
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 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.