Liverpool & Wirral
Coroner Area
Reports: 78
Earliest: Oct 2013
Latest: 7 Apr 2026
76% response rate (above 63% average).
Drew Greaves-Pimblett
All Responded
2026-0008
8 Jan 2026
NHS England
Other related deaths
Concerns summary (AI summary)
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Noted
(AI summary)
NHS England acknowledges the concerns and notes that the North West Ambulance Service followed protocol, but also outlines national work taking place around Reports to Prevent Future Deaths, ensuring learnings are shared across the NHS.
Dorothy Macdonald
All Responded
2025-0632
17 Dec 2025
Westwood Hall Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Action Taken
(AI summary)
Westwood Hall Nursing Home has adopted an approach of referring any resident who has fallen to the Falls Team, regardless of the circumstances, and staff have been made aware of this. Springcare are reviewing their Falls Policy and implementing a system to chase up referrals made to the Falls Team.
Gloria Simon (2)
All Responded
2025-0555
31 Oct 2025
Riversdale Care Home
Care Home Health related deaths
Concerns summary (AI summary)
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Action Taken
(AI summary)
The care home revised its policy regarding new residents who are out of district with their own GP to register them with a local GP. In addition, a new audit has been developed on the company's digital systems which is completed 48 hours after the resident is admitted.
Gloria Simon (1)
All Responded
2025-0554
31 Oct 2025
Marine Lake Medical Practice
Care Home Health related deaths
Concerns summary (AI summary)
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Action Planned
(AI summary)
The practice plans to review the case with the staff member involved and is investigating the case formally as part of a Significant Event Analysis. It will share the outputs of this analysis with the coroner if helpful.
Robert Evans
All Responded
2025-0120
4 Mar 2025
College of Policing
National Police Chiefs’ Council
Police related deaths
Concerns summary (AI summary)
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Noted
(AI summary)
The NPCC Stop & Search portfolio will review the Regulation 28 document and work to ensure officers are equipped to resolve incidents such as these; they will work with other portfolios and stakeholders to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them. The College of Policing asserts that its Authorised Professional Practice (APP) on Detention and Custody adequately addresses concerns about medical attention for individuals suspected of swallowing drugs, pointing to existing guidance on immediate medical response, arrest procedures, risk assessment, and information sharing.
William Bissett
All Responded
2025-0046
27 Jan 2025
HMPPS
HMP Wymott
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
Noted
(AI summary)
HM Inspectorate of Prisons acknowledges the report and states that the issues raised are covered by their inspection criteria. They will keep the findings on file and follow up as appropriate during the next inspection of HMP Wymott. HMPPS and NW Probation Service amended and re-issued the OMiC POM to COM Handover Guidance in March 2024. They are also undertaking a review of the quality of POM to COM handovers and commissioned a resettlement review. There is also a new safeguarding policy statement for Practitioners.
Diane Poole
All Responded
2025-0020
13 Jan 2025
Victoria Residential Home
Care Home Health related deaths
Concerns summary (AI summary)
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Action Taken
(AI summary)
Victoria Residential Home has already closed off the front lounge area where the escape door was located, secured the outside front door with electronic fob access, and made the conservatory door permanently inaccessible. They have also improved shift handover procedures with a senior WhatsApp group, completed new paperwork to evidence refreshments for residents, and staff have been re-enrolled on Safeguarding, Nutrition, DOLS and Communication training.
Eleanor Aldred-Owen
All Responded
2024-0695
18 Dec 2024
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
Action Taken
(AI summary)
NHS England will share the link to the HCPC proficiency standards for radiographers on the NHS Futures internet pages, Alder Hey Children’s NHS Foundation Trust has amended their SOP to address the learning required from this particular case, and they are disseminating this change. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions.
Luke Albiston O’Donnell
All Responded
2024-0678
9 Dec 2024
National Fire Chief’s Council
Office of Product Safety Standards
Product related deaths
Concerns summary (AI summary)
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack of communication and media coverage on this danger.
Action Taken
(AI summary)
NFCC supports fire and rescue services with prevention campaigns like Charge Safe, provides guidance on safe purchasing, and shares learning from incidents. The NFCC Chair has written to all Chief Fire Officers to inform them of incidents and existing resources. OPSS launched the Buy Safe, Be Safe campaign to raise awareness of e-bike and battery risks and is taking enforcement action against unsafe products. They are supporting the Product Safety Metrology Bill to update product safety regulations.
Neil Yates
All Responded
2024-0593
4 Nov 2024
NHS England & NHS Improvement
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Action Planned
(AI summary)
NHS England is working on interoperable medicine standards (IMS) to improve medication information sharing, with projects expected to roll out over the next 2-5 years. They also highlight existing screening processes in prisons.
Paul Chase
All Responded
2024-0546
14 Oct 2024
Ministry of Defence
Service Personnel related deaths
Suicide (from 2015)
Concerns summary (AI summary)
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.
Noted
(AI summary)
The Ministry of Defence expresses sympathy and highlights existing mental health support for service personnel and veterans, stating that the deceased received treatment for addiction issues before discharge, but requests to be engaged earlier in inquests where service history is relevant.
Douglas Armstrong
All Responded
2024-0440
12 Aug 2024
Medequip UK
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.
Action Taken
(AI summary)
Medequip reviewed and updated emergency responder procedures, implemented digital responder forms with risk assessments, completed first aid training for all responders, and is rolling out a bespoke People Manual Handling Training program with completion expected by January 2025.
Marlin Burrows
All Responded
2024-0230
30 Apr 2024
HMP Garth
State Custody related deaths
Concerns summary (AI summary)
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Action Planned
(AI summary)
Healthcare staff at HMP Garth have been instructed to review and sign the welfare checklist document upon arrival at the wing to inform clinical decision making, with monthly assurance checks to be completed by the Primary Care Manager. A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS. HMPPS is developing national guidance for managing prisoners under the influence of illicit substances, which is currently in the consultation stage. Once agreed, the guidance will be rolled out via regional and local drug strategy leads, who will also develop local guidance and conduct assurance checks.
Marjorie McEvoy
All Responded
2024-0050
2 Feb 2024
Clatterbridge Cancer Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
Action Taken
(AI summary)
The Clatterbridge Cancer Centre held a debrief meeting with staff involved in the inquest to discuss findings and learning points regarding clinical notation by advanced nurse practitioners.
Jessica Baker
All Responded
2023-0369
5 Oct 2023
Department for Education
Department for Transport
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety for children.
Action Planned
(AI summary)
DfT is launching a national seat belt campaign in March 2024 targeting young men. DfE will share education materials on seat belt compliance with education settings, including DfT’s updated guidance on seat belt compliance. DfE also proposes to make a small amendment to the existing statutory guidance on home-to-school travel.
Stephen Richardson
All Responded
2023-0209
22 Jun 2023
Department of Health and Social Care
NHS England & NHS Improvement
Mental Health related deaths
Concerns summary (AI summary)
There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has not improved since 2019.
Action Taken
(AI summary)
NHS England states there is constant pressure on acute psychiatry bed availability. They have taken actions linked to bed management, and all reports received are discussed by the Regulation 28 Working Group. From a CM ICB perspective wider bed management/availability issues are being continually addressed. The Department of Health and Social Care notes NHS England and Cheshire and Merseyside Integrated Care Board have provided a response. Nationally, spending on mental health services has increased by £4.7 billion, including introducing new models of care in the community.
Stuart Robinson
All Responded
2023-0161
16 May 2023
Ministry of Justice (Coroners)
Suicide (from 2015)
Concerns summary (AI summary)
Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Noted
(AI summary)
HMPPS emphasizes that the ACCT case management approach is designed to meet the specific needs of the individual by providing multi-disciplinary support. Healthcare staff are always invited to the first case review to consider the need for any additional mental health support.
Katie Wilkins
All Responded
2023-0041Deceased
26 Feb 2023
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Action Taken
(AI summary)
The Department of Health and Social Care notes that Alder Hey Children's NHS Trust undertook a Root Cause Analysis and implemented improvements, including reviewing handover arrangements. The government is also working to ensure adequate medical school places and increase doctor retention.
Beryl Ellison
All Responded
2023-0002Deceased
3 Jan 2023
CQC, Weightmans’s Solicitors and Four S…
Alcohol, drug and medication related deaths
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Action Taken
(AI summary)
Four Seasons Health Care Group has implemented improved communication, incident escalation, and medication risk assessment processes to prevent future medication errors. These include notifying management of incidents promptly, regular clinical meetings, monthly meetings to review incident management and medication audits, and medication risk assessments shared with the nursing and care team.
Philip Battle
All Responded
2022-0381
25 Nov 2022
Chief Constable
North West Ambulance Service, Director …
Suicide (from 2015)
Concerns summary (AI summary)
The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess for self-harm or coordinate mental health crisis intervention resources with police and health providers.
Noted
(AI summary)
North West Ambulance Service explains that the collaborative mental health triage car model suggested by the coroner is not suitable for the area, but that they work with partners through the Crisis Concordat to improve outcomes. Merseyside Police describes its existing mental health triage car service and explains why it does not believe a joint operability model with NWAS is appropriate, also noting NWAS has emulated the police model.
Katherine Tyrer
All Responded
2022-0307
30 Sep 2022
Cheshire and Wirral Partnership NHS Fou…
Suicide (from 2015)
Concerns summary (AI summary)
The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk assessments, leaving vulnerable patients unattended after trigger events.
Action Taken
(AI summary)
Cheshire and Wirral Partnership NHS Foundation Trust updated its Supportive Observation & Engagement Policy (CP25) to include a requirement for an automatic review when a non-registered member of staff identifies a trigger event. In addition, face-to-face clinical risk training using a formulation approach will be delivered to all in-patient staff as part of a Quality Improvement approach.
Gary Williams
All Responded
2021-0401
26 Nov 2021
National Police Chiefs’ Council
Police related deaths
Concerns summary (AI summary)
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.
Action Taken
(AI summary)
The NPCC states that following a previous similar case, the Self Defence Arrest and Restraint (SDAR) working group has already reviewed and updated training materials to include guidance on Acute Behavioural Disorder (ABD), and the updated package was circulated to forces in March 2021.
Uyapo Theodore Hayunga-Macha
All Responded
2021-0314
20 Sep 2021
Cheshire Wirral Partnership
North West Ambulance Service
Wirral University Teaching Hospital
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.
Action Planned
(AI summary)
Following an investigation into a patient death, the trust has developed and delivered an action plan addressing failures in mental health pathway commencement, risk assessment, triage delays, recognition of high-risk patients, and implementation of missing person policy; additionally, a Mental Health Transformation Group has been established. The Trust is participating in the Wirral University Teaching Hospital's Mental Health Transformation Group, addressing mental health strategy, escalation processes, training on the Mental Capacity Act, paediatric mental health, and contract monitoring.
Eva Hayden
All Responded
2021-0147
9 May 2021
Southport and Ormskirk Hospital NHS Tru…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text.
Action Taken
(AI summary)
The trust has reported the incident as a Serious Incident to the Strategic Executive Information System (StEIS) and is undertaking a full Serious Incident investigation, reviewing ongoing processes. They are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about communication with families and other organizations, and what to do when children aren't brought to their appointments.
Helen McLean
All Responded
2021-0060
3 Mar 2021
Whiston Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.
Action Taken
(AI summary)
A technical solution has been implemented to correct an IT systems error which caused failure to attach the full GP address to discharge summaries, preventing electronic transfer. Comprehensive checks have confirmed that all new discharge summaries contain the relevant GP details, and affected patients have had their discharge summaries sent to their GPs.