Liverpool & Wirral
Coroner Area
Reports: 78
Earliest: Oct 2013
Latest: 7 Apr 2026
76% response rate (above 63% average).
Jack Riding
Partially Responded
2018-0303
26 Nov 2018
Football Association
Goals Soccer Centres PLC
Other related deaths
Concerns summary (AI summary)
There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.
Action Planned
(AI summary)
The Football Association requests a copy of the Independent Consultant review of Goals Soccer Centre Plc's health and safety processes to inform a substantive response. Goals Soccer Centres Plc plan to create scenario-based training to emulate Emergency First Aid procedures in each club with all staff members and implement an annual refresher
Tom Cribley
Historic (No Identified Response)
2018-0329
9 Oct 2018
Aintree University Hospital NHS Trust
Care Quality Commission
General Medical Council
+4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Anthony Paine
Partially Responded
2018-0088
28 Mar 2018
HM Prison and Probation Service
Ministry of Justice
The Chief Coroner of England and Wales
Mental Health related deaths
State Custody related deaths
Concerns summary (AI summary)
The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Action Planned
(AI summary)
NHS England details a service specification refresh completed in March 2018, with Spectrum benchmarking against these specifications, and revisions to approaches for secure hospital transfers, including a ten-point plan "Right Care, Right Place, Right Time", are being developed. HMPPS acknowledges concerns about healthcare provision at HMP Liverpool and highlights that responsibility for healthcare provision transferred to Spectrum Community Health CiC in partnership with Mersey Care NHS Foundation Trust on April 1, 2018, aiming for a consistent approach to care continuity.
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.
Lee Swain
Historic (No Identified Response)
2017-0196
16 Jun 2017
Chester Hospital NHS Trust
Mersey Care NHS Trust
Cheshire Wirral Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.
Linsay Bushell
Partially Responded
2017-0137
25 Apr 2017
Department for Health
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.
Action Taken
(AI summary)
NHS England is investing in psychological therapies for people with personality disorders and developing guidance on high-quality services. Mersey Care NHS Foundation Trust has established a Personality Disorder Hub, devised Borderline Personality Disorder Guidelines, and provided nurse training, among other improvements.
John Jaundoo
Historic (No Identified Response)
2017-0100
29 Mar 2017
Liverpool City Council
National Offender Management Service
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public protection opportunities.
Joan Rimmer
Historic (No Identified Response)
2017-0036
3 Mar 2017
Care Quality Commission
Liverpool Community Health NHS Trust
Care Home Health related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient with severe dementia led to a two-week delay in diagnosing a fractured hip.
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.
Mark Lilliott
Historic (No Identified Response)
2016-0453
16 Dec 2016
HMP Liverpool
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.
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.
Amy Cooper
Historic (No Identified Response)
2016-0072
25 Feb 2016
Department for Health
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
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.
Lee Rushton
Historic (No Identified Response)
19 Jan 2016
102 Petty France
SW1H 9AJ
The Secretary of State for Justice
State Custody related deaths
Concerns summary (AI summary)
There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
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.
Michael McCrory
Historic (No Identified Response)
2015-0030
30 Jan 2015
Cheshire and Wirral Partnership NHS Fou…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.
Connor Smith
Partially Responded
2014-0540
17 Dec 2014
Ministry of Justice
National Offender Management Service
Prison and Probation Ombudsman
State Custody related deaths
Concerns summary (AI summary)
An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder learning from incidents.
Noted
(AI summary)
The PPO acknowledges a minor factual inaccuracy in their report, but argues it had no material bearing on the circumstances of the death and that they cannot take further action beyond the original recommendations to the prison. HMP Altcourse has issued a notice to all senior managers who chair Segregation Review Boards, advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded.
David Thomson
Historic (No Identified Response)
2014-0447
16 Oct 2014
Department for Business, Innovation and…
Product related deaths
Concerns summary (AI summary)
E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies the wrong current.
Wilfred Aspinwall
Historic (No Identified Response)
2014-0283
25 Jun 2014
Prison and Probation Ombudsman
State Custody related deaths
Concerns summary (AI summary)
Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Charles Bradley
Historic (No Identified Response)
2014-0118
17 Mar 2014
Arrowe Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Anthony Hughes
Historic (No Identified Response)
2013-0352
9 Dec 2013
National Crime Agency
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the specific case.
Damion Anthony Andre Martin
Historic (No Identified Response)
2013-0280
30 Oct 2013
NOMS
HMP Liverpool
Rights and Responsibilities Group
State Custody related deaths
Concerns summary (AI summary)
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.