Sefton, St Helens and Knowsley
Coroner Area
Reports: 77
Earliest: Oct 2013
Latest: 5 Feb 2026
75% response rate (above 62% average).
Eva Hayden
All Responded
2021-0147
9 May 2021
Southport and Formby District General H…
Southport and Ormskirk Hospital NHS Tru…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
No specific concerns were detailed in the provided text.
Helen McLean
All Responded
2021-0060
3 Mar 2021
Whiston Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.
Carl Newman
All Responded
2020-0056
6 Mar 2020
HMPPS
State Custody related deaths
Suicide (from 2015)
Concerns 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.
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
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.
Ceara Thacker
All Responded
2025-0249
30 Sep 2019
NHS England
Suicide (from 2015)
Concerns 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.
Lucia Stear
All Responded
2019-0296
13 Sep 2019
Communities & Local Government
Department of Housing
Child Death (from 2015)
Other related deaths
Concerns 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.
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
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.
Anthony Paine
All Responded
2018-0088
28 Mar 2018
Ministry of Justice
HM Prison and Probation Service
Mental Health related deaths
State Custody related deaths
Concerns summary
The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Paul Maddox
All Responded
2017-0220
17 Sep 2017
Wirral University Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Sam Molyneux
All Responded
2017-0340
13 Sep 2017
HM Prison & Probation Service
State Custody related deaths
Concerns 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).
Edwin O’Donnell
All Responded
2017-0258
13 Jul 2017
HM Prison and Probation Services
State Custody related deaths
Concerns 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.
Paul Briggs
All Responded
2017-0040
28 Feb 2017
Merseyside Passenger Transport Authority
Road (Highways Safety) related deaths
Concerns 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.
Roy Hoey
All Responded
2016-0360
13 Oct 2016
National Offender Management Service
State Custody related deaths
Concerns 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.
Ronald Volante
All Responded
2016-0499
28 Jan 2016
Magenta Living Support Link
Other related deaths
Concerns 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.
Stephen O’Malley
All Responded
2015-0363
14 Sep 2015
SubCPartner
Accident at Work and Health and Safety related deaths
Concerns 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.
Luke Myers
All Responded
2015-0292
20 Jul 2015
National Offenders Management Service
State Custody related deaths
Concerns 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.
Isabella Hope Hill
All Responded
2013-0281
23 Oct 2013
Liverpool Womens Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 summary
The Trust has revised its UVC insertion guideline and proforma, enhanced staff education, clarified radiology service level agreements for neonatal X-rays to ensure a 60-minute turnaround, and provide
Rosa Anderson
All Responded
2013-0263
17 Oct 2013
Aintree Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Action taken summary
Aintree University Hospital has already implemented a discharge advice sheet for laparoscopic procedures, which is provided to all relevant patients prior to discharge. They are also implementing gene