Sefton, St Helens and Knowsley
Coroner Area
Reports: 77
Earliest: Oct 2013
Latest: 5 Feb 2026
75% response rate (above 62% average).
Drew Greaves-Pimblett
All Responded
2026-0008
8 Jan 2026
NHS England
Other related deaths
Concerns summary
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Action taken summary
NHS England, through liaison with North West Ambulance Service (NWAS), reports that NWAS has reviewed and amended its Medical Priority Dispatch System (MPDS) guidance for call handlers, introducing cl
Dorothy Macdonald
All Responded
2025-0632
17 Dec 2025
Westwood Hall Nursing Home
Care Home Health related deaths
Concerns summary
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Action taken summary
Springcare has revised falls risk assessment documentation, introduced new falls training for existing and new staff, and begun auditing assessments. Westwood Hall has also implemented a new policy to
Gloria Simon (1)
All Responded
2025-0554
31 Oct 2025
Marine Lake Medical Practice
Care Home Health related deaths
Concerns summary
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Action taken summary
Marine Lake Medical Practice acknowledges the care provided was below expected standards and plans a formal Significant Event Analysis to review the case. They will also review and take action …
Gloria Simon (2)
All Responded
2025-0555
31 Oct 2025
Riversdale Care Home
Care Home Health related deaths
Concerns summary
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Action taken summary
Riversdale Care Home has updated its 'Request for Care Form' to correctly identify as a 'Care Home'. They have also revised their policy to send letters to out-of-district GPs for …
Robert Evans
All Responded
2025-0120
4 Mar 2025
College of Policing
National Police Chiefs’ Council
Police related deaths
Concerns summary
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Action taken summary
The NPCC disputes the suggestion that officers cannot share information with next of kin in vital interest situations, stating existing national training covers this. For other concerns, the Stop & …
Nicola Owens
All Responded
2025-0053
31 Jan 2025
NHS England & NHS Improvement
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Concerns summary
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response capacity.
Action taken summary
NHS England is actively implementing its Urgent & Emergency Care Recovery Plan, with regional teams working to improve patient flow, grow the workforce, and reduce handover delays. Three workstreams (
William Bissett
All Responded
2025-0046
27 Jan 2025
HMPPS
HMP Wymott
State Custody related deaths
Suicide (from 2015)
Concerns summary
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
Action taken summary
HMI Prisons acknowledges the concerns regarding pre-release arrangements for prisoners, noting that these issues are covered by their existing inspection criteria. They will keep the findings on file
Diane Poole
All Responded
2025-0020
13 Jan 2025
Victoria Residential Home
Care Home Health related deaths
Concerns summary
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Action taken summary
Victoria Residential Home has implemented several measures, including daily rigorous alarm checks, increasing staff numbers by two per shift, improving shift handover procedures, and restructuring the
Eleanor Aldred-Owen
All Responded
2024-0695
18 Dec 2024
NHS England
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
Action taken summary
NHS England will share links to HCPC proficiency standards for radiographers on NHS Futures to remind staff of their responsibilities. They also note that Alder Hey Children’s NHS Foundation Trust …
Luke Albiston O’Donnell
All Responded
2024-0678
9 Dec 2024
National Fire Chief’s Council
Office of Product Safety Standards
Product related deaths
Concerns summary
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack of communication and media coverage on this danger.
Action taken summary
The NFCC has an existing "Charge Safe" campaign and signposts to OPSS "Buy Safe, Be Safe" guidance to raise public awareness of lithium-ion battery risks. They have also liaised with …
Neil Yates
All Responded
2024-0593
4 Nov 2024
NHS England & NHS Improvement
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Concerns summary
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Action taken summary
NHS England acknowledges the delay in sharing prescribing information and is implementing several initiatives, including defining interoperable medicine standards and advancing the Digital Medicines P
Amanda Gainford
All Responded
2024-0571
21 Oct 2024
NHS England
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.
Action taken summary
NHS England highlights its existing National Framework for healthcare professional ambulance responses, last updated in March 2021, which details the process for HCP requests and explicitly allows cli
Paul Chase
All Responded
2024-0546
14 Oct 2024
Ministry of Defence
Service Personnel related deaths
Suicide (from 2015)
Concerns summary
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.
Action taken summary
The Ministry of Defence disputes the premise of a lack of support, stating that Defence has provided prompt mental health and addiction support for several years, including treatment for Mr …
Douglas Armstrong
All Responded
2024-0440
12 Aug 2024
Medequip UK
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.
Action taken summary
Medequip conducted a thorough review of their Responder Service procedures and implemented new digital forms for risk assessments and visits, which went live on 1 July 2024. They also completed …
Marlin Burrows
All Responded
2024-0230
30 Apr 2024
HMP Garth
State Custody related deaths
Concerns summary
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Marjorie McEvoy
All Responded
2024-0050
2 Feb 2024
Clatterbridge Cancer Centre
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
Jessica Baker
All Responded
2023-0369
5 Oct 2023
Department for Transport
Department for Education
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary
Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety for children.
Stephen Richardson
All Responded
2023-0209
22 Jun 2023
NHS England & NHS Improvement
Department of Health and Social Care
Mental Health related deaths
Concerns summary
There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has not improved since 2019.
Stuart Robinson
All Responded
2023-0161
16 May 2023
Ministry of Justice (Coroners)
Suicide (from 2015)
Concerns summary
Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Katie Wilkins
All Responded
2023-0041Deceased
26 Feb 2023
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Philip Battle
All Responded
2022-0381
25 Nov 2022
Director of Publish Health and Police a…
North West Ambulance Service
Suicide (from 2015)
Concerns summary
The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess for self-harm or coordinate mental health crisis intervention resources with police and health providers.
Katherine Tyrer
All Responded
2022-0307
30 Sep 2022
Cheshire and Wirral Partnership NHS Fou…
Suicide (from 2015)
Concerns summary
The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk assessments, leaving vulnerable patients unattended after trigger events.
Sarah-Louise Doyle
All Responded
2022-0070
4 Mar 2022
Mersey Care NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Gary Williams
All Responded
2021-0401
26 Nov 2021
National Police Chiefs’ Council
Police related deaths
Concerns summary
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.
Uyapo Theodore Hayunga-Macha
All Responded
2021-0314
20 Sep 2021
Wirral University Teaching Hospital
North West Ambulance Service
Cheshire Wirral Partnership
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.