Liverpool & Wirral

Coroner Area
Reports: 78 Earliest: Oct 2013 Latest: 7 Apr 2026

76% response rate (above 63% average).

Response Status
Responded 59 Historic 18 Pending 1
AI Classification
Action Taken 47%
Action Planned 31%
Noted 22%
Disputed 0%
Based on 74 classified responses
Top Categories
Hospital Death (Clinical Procedure… (26) State Custody related deaths (14) Care Home Health related deaths (9) Suicide (from 2015) (9) Alcohol, drug and medication relat… (7)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North West average: -42 reports · +13pp response rate
vs national average: -6 reports · +13pp response rate
78 results
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.
Matthew Dale
Historic (No Identified Response)
2023-0028Deceased 26 Jan 2023
Department of Health and Social Care
Care Home Health related deaths
Concerns summary (AI summary) Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and actual care, hindering proper support for his complex needs.
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.
Susan Skillen
Historic (No Identified Response)
2022-0367 16 Nov 2022
NHS England NHS Improvement
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a review of literature and adverse event reporting.
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.
Joan Richardson
Partially Responded
2022-0205 1 Jul 2022
Care Quality Commission Litch Care for Action
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training and escalation procedures for deteriorating patients were inadequate, leading to undocumented pressure ulcers.
Action Planned (AI summary) Litch Care Service describes existing practices for managing risk, monitoring care, and promoting learning, stating that these will be monitored monthly throughout team meetings and staff supervisions; no specific new actions are detailed.
Sergio Dunkley
Historic (No Identified Response)
2022-0140 12 May 2022
Care Quality Commission NHS England
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.
Sarah-Louise Doyle
Partially Responded
2022-0070 4 Mar 2022
Mersey Care NHS Foundation Trust Merseyside Police
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Action Taken (AI summary) The Trust has already taken actions, including issuing urgent instructions on recording intermittent observations, discussing the report at safety huddles, ensuring competency updates for staff, conducting spot checks on observation forms, and reviewing the Ward Assurance Audit to reflect the need for unpredictable observation intervals.
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.
Brian Jackson
Partially Responded
2021-0246 16 Jul 2021
Liverpool Heart and Chest Hospital National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Action Planned (AI summary) NICE acknowledges concerns and will consider them during an update to its guideline on delirium, focusing on risk assessment and diagnosis, including in ICU settings.
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.
Pauline Brumfitt
Partially Responded
2021-0098 6 Apr 2021
Care Quality Commission Widnes Hall Care Home
Care Home Health related deaths
Concerns summary (AI summary) The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Action Taken (AI summary) Anchor Hanover Group has reviewed and updated training, policies and procedures, introduced more formal triage arrangements, additional handover guidance, and improvements to Care Quality Indicators.
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.
Grant Macdonald
Partially Responded
2020-0131 15 Jun 2020
Liverpool City Council Merseyside Police
Road (Highways Safety) related deaths
Concerns summary (AI summary) The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles performing U-turn maneuvers across the carriageway to a central reservation.
Noted (AI summary) Liverpool City Council acknowledges the concerns regarding a fatality on Hornby Road, but states that no engineering measures, signage, lines or physical infrastructure contributed to the collision. They will continue to monitor the route, but do not consider there is adequate justification to close the gaps in the central reservation at this time.
Carl Newman
All Responded
2020-0056 6 Mar 2020
HMPPS
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
Action Taken (AI summary) Following the inquest, the Governor of HMP Liverpool issued a staff information notice promoting the use of the myLearning system for accessing training records, and a comprehensive guide on how to use the system will follow. The ACCT case management system is being updated and training packages refreshed.
Anthony Carroll
All Responded
2020-0018 8 Jan 2020
National Police Chief’s Council
Emergency services related deaths (2019 onwards) Road (Highways Safety) related deaths
Concerns summary (AI summary) The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a safety flaw.
Noted (AI summary) The NPCC provides clarification on police vehicle speed limits and emergency equipment operation, stating that there's no national proposal to add further equipment activation indicators due to potential driver distraction.
Ceara Thacker
Partially Responded
2025-0249 30 Sep 2019
NHS England NHS Improvement, Patient Safety Team
Suicide (from 2015)
Concerns summary (AI summary) Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked training on safe intervention for hangings.
Action Planned (AI summary) NHS England will focus on ensuring consent is reliably and consistently considered for family involvement in mental health care, particularly regarding complex electronic patient record systems and differing patient needs. They are also working with Universities UK to develop information sharing guidance and a consensus statement on sharing information without breaching confidentiality.
Lucia Stear
All Responded
2019-0296 13 Sep 2019
Department of Housing, Communities & Lo… Local Government Association
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.
Noted (AI summary) The LGA will include an item in its email bulletins to local authority chief executives and environmental officers, will host an online event with relevant officers by the end of December 2019, and will liaise with the Ministry of Housing, Communities and Local Government to address recommendations nationally. The Ministry acknowledges the coroner's concerns and highlights the increase in Core Spending Power for local government and the allocation of funds for park renovations, noting that spending on parks is a matter for local authorities.
Lewis Doyle
Partially Responded
2019-0214 24 Jun 2019
Department of Health and Social Care NHS England NHS Improvement
Railway related deaths
Concerns summary (AI summary) Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original prescribers regarding suspended medications.
Noted (AI summary) The Department of Health and Social Care acknowledges the concerns about communication between medical practitioners and refers to existing NHS Standard Contract requirements and professional duties regarding information sharing, but does not commit to specific new actions. NHS England and NHS Improvement are connecting organisations to the Cheshire and Merseyside health and care record sharing platform, which includes the ability to share discharge summaries and clinic letters, with technical completion due by March 2021.
Barry Fullarton
All Responded
2019-0159 17 May 2019
Cheshire and Wirral NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when mood is low.
Action Planned (AI summary) The Trust will develop and share a learning bulletin to outline the importance of responding to assessments for DMV, to be circulated to clinical teams by the end of July 2019. This learning will also be shared at a Trustwide Grand Round in September 2019 and included in the Suicide Prevention Training.
Michal Netyks
Partially Responded
2018-0393 19 Dec 2018
Home Office MOJ
State Custody related deaths
Concerns summary (AI summary) Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.
Action Taken (AI summary) HMP Altcourse has updated NOMIS with a record of risk assessment conversations and issued a notice to staff reminding them to use the Big Word translation service. The MoJ Estates Directorate has agreed to carry out a review of balcony design, expected to be completed in the autumn.