Northumberland

Coroner Area
Reports: 26 Earliest: Jan 2014 Latest: 26 Mar 2026

85% response rate (above 63% average).

Clear 19 results
Elizabeth Lang and Katie Lang
All Responded
2026-0182 26 Mar 2026
Northumberland County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting unfamiliar drivers to the severity of the bend where the collision occurred.
Action Taken (AI summary) • The location on the A1068 Sheepwash Road has been identified and recorded by the Council’s Highways service as a high-risk site for the purposes of traffic safety assessment. • The site has already been subject to resurfacing and road marking works during 2025/26 and has also been included within the 2026–2027 Local Transport Plan programme for traffic safety improvements. • The Council has now commenced a review of the site to consider options to improve the visibility and awareness of the bend for road users, including the potential use of advance warning measures.
Ellen Taylor
All Responded
2026-0079
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and routine consideration.
1 response from NHS England
Joan Whitworth
All Responded
2025-0390 29 Jul 2025
Hillcare Group Northumbria Healthcare NHS Foundation T…
Care Home Health related deaths
Concerns summary (AI summary) There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.
Action Planned (AI summary) Hill Care Group has changed the electronic platform to record staff training, adding an alert function and automated compliance reports for the Home Manager. They have also added additional checks to governance systems, and revised agency worker check process including skills and training. The Trust is developing a Standard Operating Procedure (SOP), expected to be completed by October 2025, to guide staff in clarifying discrepancies in referrals by requesting key documents from Care Home staff and specifying clinical triggers for face-to-face assessments.
REDACTED
All Responded
2025-0314 23 Jun 2025
49 Marine Avenue Surgery Department of Health and Social Care Moorbridge School +2 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.
Noted (AI summary) The North East and North Cumbria Integrated Care Board acknowledges the concerns, noting the existing systems for patient record sharing via the Great North Care Record and the responsibility of medical professionals within multidisciplinary teams. They also refer to NHS England guidance on outpatient services. Moorbridge School has conducted a thorough review of their practices related to information sharing and safeguarding and will revisit and reinforce staff understanding of these policies through annual refresher training. 49 Marine Avenue GP Surgery acknowledges shortcomings and will strengthen communication with secondary care, improve multidisciplinary communication, and review safeguarding procedures. They will also implement new guidelines for monitoring, supporting families, and provide staff training in eating disorder management. The Trust has implemented a restructure within the Dietetics Service, introduced mandatory training for staff on safeguarding children, and will discuss information sharing between primary and secondary healthcare at the NENC GP Provider interface group by October 2025. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue and aim to have a Single Patient Record processing information by 2028.
Malcolm Morris
All Responded
2025-0239 21 May 2025
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.
Action Taken (AI summary) NHS England highlights the Frontline Digitisation Programme to improve information sharing, and the STSFT is conducting a clinician review of discharge processes with findings to be shared with the ICB and NHS England; the NHFT has started an audit of communication arrangements and implemented a hub model to support clinical triage.
Renate Mark
All Responded
2025-0149 18 Mar 2025
NORTHUMBRIA HEALTHCARE NHS FOUNDATION T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for high-risk patients. Inadequate scrutiny of witness statements hinders learning.
Action Planned (AI summary) The Trust is briefing ward staff on the definitions of 'witnessed' and 'unwitnessed' falls and the importance of accurate terminology and will involve Governance Leads in internal investigations to ensure in-depth scrutiny of witness accounts.
Elise Walsh
All Responded
2024-0467 22 Aug 2024
Cumbria, Northumberland, Tyne and Wear …
Suicide (from 2015)
Concerns summary (AI summary) Administrative staff do not read complaint forms, placing them in envelopes to be sent to another hospital, raising concerns important patient information could be missed or treatment delayed; the family was also not made aware of the complaint form's existence in a timely manner.
Action Taken (AI summary) The Trust has redesigned internal review templates to ensure identified issues are not lost, reminded investigating officers to explore raised issues, and added a note to the complaints form directing urgent concerns to the crisis team. They have also implemented a system where clinicians support reception staff with patient concerns and can review written notes.
Harry Hall
All Responded
2024-0234 1 May 2024
Cumbria, Northumberland, Tyne and Wear …
Mental Health related deaths
Concerns summary (AI summary) Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor record-keeping.
Action Taken (AI summary) The Trust clarified that the appointment was created in error by an administrator and outlines existing processes for appointment cancellations, highlighting documentation procedures and communication protocols.
Eleanor Smith
All Responded
2024-0193 12 Apr 2024
Northumbria Healthcare NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of medical records.
Action Taken (AI summary) Northumbria Healthcare NHS Foundation Trust has updated its medicines policy (MM01) to ensure medication administration and IV cannulation are clearly and legibly recorded. The trust is also focusing on the recognition of all-cause patient deterioration and delivering key interventions.
Julie Nolan
All Responded
2023-0162 11 May 2023
Maria Mallaband Care Group and Countryw…
Care Home Health related deaths
Concerns summary (AI summary) Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.
Action Taken (AI summary) Maria Mallaband care home has retrained staff regarding wound management and documentation, reviewed staffing levels, and reinforced the importance of escalating concerns to Tissue Viability. A national webinar was also held to discuss the inquest findings and the importance of documentation.
Allan Waddup
All Responded
2022-0343 10 Aug 2022
Tees, Esk and Wear Valley NHS
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person follow-up before discharge, and urgent weekend referrals were not triaged.
Action Taken (AI summary) Appointment letter templates have been reviewed and updated and have now been introduced across all prison establishments, including HMP Northumberland, to notify inmates of planned appointments. Also, the prison service provider at HMP Northumberland has granted the request to remove the ability to refer to mental health services via kiosk and posters have been produced and displayed on the wings providing information about how to refer to the mental health team.
Margaret Greenacre
All Responded
2022-0119 17 Feb 2021
Baedling Manor Care Home
Care Home Health related deaths
Concerns summary (AI summary) The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Action Planned (AI summary) The care home is under notification to close and transitioning to a new provider. The new management team is developing safe operation of the home including enhanced leadership, new compliance and care planning systems, increased training, and health and safety audits.
Lesley Armstrong
All Responded
2019-0136 4 Apr 2019
Northumbria Police
Police related deaths
Concerns summary (AI summary) Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.
Disputed (AI summary) Northumbria Police argues that it already has a system for reminding officers to inform suspects of the outcome of police investigations, that decisions to disclose information to employers can only be made on a case-by-case basis, and that providing information to employers as a 'fail safe' mechanism would be unlawful without the employee's consent, therefore no further action is deemed necessary.
Maurice Wrightson
All Responded
2017-0372 13 Dec 2017
Volvo Group (UK) Limited
Road (Highways Safety) related deaths
Concerns summary (AI summary) Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.
Disputed (AI summary) Volvo Group UK does not support the statement that using automatic gear mode exacerbates brake fade in long descents, arguing that the correct use of the retarder is more important than the gearbox mode.
Daniel Campbell
All Responded
2017-0122 13 Apr 2017
Network Rail
Railway related deaths
Concerns summary (AI summary) Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
Action Planned (AI summary) Network Rail has included fencing upgrades in their 2018 renewals plan for the section of track where the incident occurred. Further works will be planned to improve the robustness of the boundary.
Barbara Patterson
All Responded
2015-0198 21 May 2015
Care Quality Commission Department of Health and Social Care North East Ambulance Service NHS Founda…
Community health care and emergency services related deaths
Concerns summary (AI summary) The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Noted (AI summary) NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of working, and will work to increase the number of Physician Associate training programmes. HEE will also ensure that paramedic training provides an additional 16% growth. The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance Service in September 2015. They will also meet to monitor NEAS staffing levels and recruitment. The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Vincent Oliver
All Responded
2014-0438 9 Oct 2014
HMP Northumberland
State Custody related deaths
Concerns summary (AI summary) A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.
Action Taken (AI summary) HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change.
Samuel Shaw
All Responded
2014-0076 26 Feb 2014
Highways Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and no central refuge.
Action Planned (AI summary) The Highways Agency has arranged for an investigation to consider options for an improved pedestrian crossing facility in the vicinity of Haggerston. The investigation will assess demand, appraise existing routes, and identify suitable locations.
Jack Lynn
All Responded
2014-0066 18 Feb 2014
Nightingale Home Help Service
Community health care and emergency services related deaths
Concerns summary (AI summary) The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Action Taken (AI summary) Nightingales Home Help Service will encourage clients to have medication charts and has advised staff to review their medication policy. They also provided a Safe Handling of Medication course for staff in October 2013 and issued a verbal warning to the employee involved in the incident.