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
Clear 40 results
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.
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.
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.
Paul Maddox
All Responded
2017-0220 17 Sep 2017
Wirral University Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in adopting patient safety improvements post-Root Cause Analysis.
Action Taken (AI summary) Wirral University Teaching Hospitals NHS Foundation Trust has changed the lab IT system and issued an action notice to staff, changing the delta check value for Hb from 25% to 20% and the telephone criteria from less than 70g/l to less than 75g/l.
Sam Molyneux
All Responded
2017-0340 13 Sep 2017
HM Prison & Probation Service
State Custody related deaths
Concerns summary (AI summary) Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Action Planned (AI summary) HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training.
Edwin O’Donnell
All Responded
2017-0258 13 Jul 2017
HM Prison and Probation Services
State Custody related deaths
Concerns summary (AI summary) Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Action Taken (AI summary) The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT, and suicide and self-harm training is being rolled out to all staff.
Paul Briggs
All Responded
2017-0040 28 Feb 2017
Merseyside Passenger Transport Authority
Road (Highways Safety) related deaths
Concerns summary (AI summary) The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles inadvertently straying into oncoming traffic, particularly where visibility is inhibited.
Action Planned (AI summary) Merseyside Passenger Transport Authority will engage a contractor to install rumble strips within the white lines in the area concerned, aiming to instruct the contractor by the end of the following week.
Roy Hoey
All Responded
2016-0360 13 Oct 2016
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Action Planned (AI summary) NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will be easier for staff to read and understand.
Ronald Volante
All Responded
2016-0499 28 Jan 2016
Magenta Living Support Link
Other related deaths
Concerns summary (AI summary) Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to revisit the training manual and methods.
Action Taken (AI summary) Magenta Living updated their community alarm operator procedures to proactively provide medical history to the ambulance service, trained staff on the new procedure, and will include this in future inductions. They also perform audits and monitor staff to ensure smooth implementation.
Stephen O’Malley
All Responded
2015-0363 14 Sep 2015
SubCPartner
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.
Noted (AI summary) SubC Partner refers to Danish authority findings, states it performs pre-dive checks according to standards and customer approval, and uses certified personnel. The response appears to be a pre-dive checklist form.
Luke Myers
All Responded
2015-0292 20 Jul 2015
National Offenders Management Service
State Custody related deaths
Concerns summary (AI summary) HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.
Action Taken (AI summary) HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational Support Grade staff will also be trained.
Isabella Hope Hill
All Responded
2013-0281 23 Oct 2013
Liverpool Womens Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.
Action Taken (AI summary) The Trust has enhanced local education for staff on the Neonatal Unit regarding revised guidelines, reviewed and clarified the Service Level Agreement for Radiology to ensure X-rays are performed within 60 minutes, and is working to increase the use of the electronic patient administration system (Badger) through additional education sessions.
Rosa Anderson
All Responded
2013-0263 17 Oct 2013
Aintree Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Action Taken (AI summary) Aintree University Hospital has implemented a discharge advice sheet for laparoscopic procedures and is providing generic leaflets for all discharged patients, with specialties developing individualized discharge information sheets by March 2014.
Yousef Shokri-Gharab
All Responded
2013-0239-wp23943 14 Oct 2013
Mersey Care, NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Action Taken (AI summary) • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • The policy that provided concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated.