Sefton, St Helens and Knowsley

Coroner Area
Reports: 77 Earliest: Oct 2013 Latest: 5 Feb 2026

75% response rate (above 62% average).

Response Status
Responded 58 Historic 16 Pending 1
AI Classification
Action Taken 52%
Action Planned 26%
Noted 9%
Disputed 13%
Based on 23 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 16 results
Julia Murphy
Historic (No Identified Response)
2023-0490 30 Nov 2023
Abbey Wood Lodge Care Home
Care Home Health related deaths
Concerns summary The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.
Wayne Milne
Historic (No Identified Response)
2023-0393 19 Oct 2023
Rocky Lane Medical Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.
Matthew Dale
Historic (No Identified Response)
2023-0028Deceased 26 Jan 2023
Department of Health and Social Care
Care Home Health related deaths
Concerns 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.
Susan Skillen
Historic (No Identified Response)
2022-0367 16 Nov 2022
NHS England and NHS Improvement
Alcohol, drug and medication related deaths Other related deaths
Concerns 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.
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 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.
Tom Cribley
Historic (No Identified Response)
2018-0329 9 Oct 2018
NHS England Public Health England Nursing and Midwifery Council +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.
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.
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.
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.
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.
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.
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.
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.