Norfolk
Coroner Area
Reports: 123
Earliest: Aug 2013
Latest: 18 Mar 2026
82% response rate (above 63% average).
Darren Wright
All Responded
2015-0035
2 Feb 2015
HMP Norwich
Serco
Virgin Care Limited
State Custody related deaths
Concerns summary (AI summary)
Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.
Noted
(AI summary)
Serco states that they were the healthcare provider at HMP Norwich at the time of the death but no longer provide any services there and thus cannot implement the recommendations. They note that the report has been sent to HMP Norwich and Virgin Care. Virgin Care, the current healthcare provider at HMP Norwich, has instituted changes to its procedures, including a local induction process and checklist, and guidance for resuscitation in a joint protocol with HM Prison Service. These were put in place by March 31, 2015. HMP Norwich acknowledges the coroner's concerns regarding CPR training, outlines the current legislation and risk assessment process for first aid needs, and states that there is no requirement to provide AEDs or defibrillator training. They highlight the presence of a healthcare team providing 24-hour cover.
Martha Seaward
All Responded
2015-0033
2 Feb 2015
Norfolk County Council
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety improvements, despite previous warnings.
Action Planned
(AI summary)
Norfolk County Council outlines its legal duties and proposes improvements at Lodge Hill junction in 2015/16. This includes a "trod" footpath, verge lowering, and information signs to improve pedestrian safety.
Robert Anstice
Historic (No Identified Response)
2015-0014
16 Jan 2015
Norfolk and Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.
David Mountain
All Responded
2014-0554
24 Dec 2014
Queen Elizabeth Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.
Action Taken
(AI summary)
The Queen Elizabeth Hospital has implemented clear guidance for doctors on investigating patients admitted after pacemaker insertion and implemented a system for cardiac technicians to directly contact clinical teams about abnormal results. The hospital is moving to an electronic reporting system and cardiology consultants are routinely present on site on weekends.
Darren Hayes
All Responded
2014-0538
17 Dec 2014
Norfolk County Council
Other related deaths
Concerns summary (AI summary)
Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health providers were also not contacted for assistance.
Action Taken
(AI summary)
Norfolk County Council has taken action regarding the individual worker involved and the Adult Social Services Quality Assurance Team is developing a Best Practice factsheet to formalise local custom and practice regarding contacting people referred to the Service.
Joanne Nobbs
All Responded
2014-0560
4 Dec 2014
Norfolk and Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care plan was not revised despite the deceased no longer engaging with mental health services.
1 response
from Norfolk and suffolk NHS Trust
Michael Harman
All Responded
2014-0514
25 Nov 2014
Centra Support
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.
Action Taken
(AI summary)
Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users after incidents, and making referrals.
Richard Turner
Historic (No Identified Response)
2014-0513
25 Nov 2014
FALCON CRANE HIRE LIMITED
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.
Jackson Mitchell
Partially Responded
2014-0468
27 Oct 2014
NHS England
Norfolk and Norwich University Hospital…
Queen Elizabeth Hospital King’s Lynn NH…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.
Action Taken
(AI summary)
The Trust conducted an internal review, shared findings at paediatric governance meetings, and introduced a new X-ray review checklist. Regionally, guidelines are being developed (King's Lynn is already following them), and nationally, NHS England and BAPM are working on new guidance for central venous lines, with publication expected in autumn 2015.
Ann Wells
Historic (No Identified Response)
2014-0401
11 Sep 2014
Norfolk and Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Graeme Kidd
Historic (No Identified Response)
2014-0337
23 Jul 2014
Norfolk and Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.
Sol Hadhasseh
Historic (No Identified Response)
2014-0272
17 Jun 2014
Coventry and Warwickshire Partnership N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.
Simon Haines
Historic (No Identified Response)
2014-0236
22 May 2014
Norfolk County Council
Community health care and emergency services related deaths
Concerns summary (AI summary)
There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.
Margaret Connor
All Responded
2014-0215
9 May 2014
Heathers Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.
Action Taken
(AI summary)
The nursing home asserts it already meets required standards for equipment maintenance and staff training. They are implementing weekly wheelchair checks and providing staff with updated guidelines, including a wheelchair safety checklist to be used each time a resident uses a wheelchair.
Darren Arnoup
Partially Responded
2014-0199
1 May 2014
Mundesley Medical Centre
NHS North Norfolk Clinical Commissionin…
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Action Planned
(AI summary)
The medical centre will develop clear lines of communication with NCH&C staff, alert GPs to referrals related to mental health or substance misuse, and ensure GPs fully document any areas of mental upset or instability discussed for the information of successive colleagues.
Kathryn Sawyer
All Responded
2014-0177
16 Apr 2014
Roundwell Medical Centre
Community health care and emergency services related deaths
Concerns summary (AI summary)
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.
Action Taken
(AI summary)
Roundwell Medical Centre has implemented several immediate actions regarding patients on addictive medications including assigning a single GP where possible, detailing clinical plans, adding read codes for easy identification, and a six-month medication review. They will design a bespoke "Addictive Medication Review" template within 3 months and include patients on weekly medication in risk profiling.
Susan Poore
Historic (No Identified Response)
2014-0140
28 Mar 2014
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
Sebastian Davies
Historic (No Identified Response)
2014-0139
28 Mar 2014
Norvic Clinic
Community health care and emergency services related deaths
Concerns summary (AI summary)
Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Derrick Plater
All Responded
2014-0130
21 Mar 2014
Cambridgeshire County Council
Community health care and emergency services related deaths
Concerns summary (AI summary)
There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Disputed
(AI summary)
The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and placement process.
Ryan Pettengell
Historic (No Identified Response)
2014-0096
4 Mar 2014
Borough Council of King’s Lynn & West N…
Norfolk County Council
Norfolk Police
+1 more
Other related deaths
Concerns summary (AI summary)
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.
Yuki Ivy Norman-Knight
All Responded
2013-0321
4 Dec 2013
St Stephens Gate Medical Practice
Community health care and emergency services related deaths
Concerns summary (AI summary)
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
Action Taken
(AI summary)
St Stephens Gate has reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. They are arranging laminated copies of the NICE Traffic Light guidance to be present on desks in all nurses' consulting rooms and have discussed the outcomes of this case at practice clinical meetings and reviewed policies and procedures accordingly.
Matthew Dunham
Historic (No Identified Response)
2013-0229
12 Sep 2013
Norfolk and Suffolk NHS Foundation Trust
Mental Health related deaths
Concerns summary (AI summary)
Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Ronald Sherlock
Historic (No Identified Response)
2013-0181
9 Aug 2013
Serco
State Custody related deaths
Concerns summary (AI summary)
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.