Sefton, St Helens and Knowsley
Coroner Area
Reports: 77
Earliest: Oct 2013
Latest: 5 Feb 2026
75% response rate (above 62% average).
Tom Cribley
Historic (No Identified Response)
2018-0329
9 Oct 2018
NHS England
Nursing and Midwifery Council
NHS South Sefton Clinical Commissioning…
+4 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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
All Responded
2018-0088
28 Mar 2018
HM Prison and Probation Service
Ministry of Justice
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.
Lee Swain
Historic (No Identified Response)
2017-0196
16 Jun 2017
Chester Hospital NHS Trust
Mersey Care NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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
A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.
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
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
Liverpool Community Health NHS Trust
Care Home Health related deaths
Community health care and emergency services related deaths
Concerns 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
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.
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
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
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.
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
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
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.
Lee Rushton
Unknown
19 Jan 2016
State Custody related deaths
Concerns 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
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.
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
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
National Offender Management Service
Prison and Probation Ombudsman
Ministry of Justice
State Custody related deaths
Concerns 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.
David Thomson
Historic (No Identified Response)
2014-0447
16 Oct 2014
Department for Business
Innovation and Skills
Product related deaths
Concerns 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
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
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
Unknown
2013-0352
9 Dec 2013
Alcohol, drug and medication related deaths
Concerns 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
Rights and Responsibilities Group
State Custody related deaths
Concerns 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.
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