Northamptonshire

Coroner Area
Reports: 49 Earliest: Sep 2014 Latest: 19 Feb 2026

71% response rate (above 62% average).

Response Status
Responded 35 No Response 2 Historic 9 Pending 3
AI Classification
Action Taken 78%
Action Planned 11%
Noted 11%
Disputed 0%
Based on 9 classified responses
Top Categories
Hospital Death (Clinical Procedure… (20) Road (Highways Safety) related dea… (8) Suicide (from 2015) (7) Alcohol, drug and medication relat… (5) Care Home Health related deaths (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East Midlands average: -19 reports · +7pp response rate
vs national average: -34 reports · +9pp response rate
49 results
Jane Fenwick
Response Pending
2026-0104 19 Feb 2026
NHS England Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, despite a care plan recommending observation.
Akhona Moyo
Response Pending
2026-0045 28 Jan 2026
Department of Health and Social Care NHS England Northampton General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Heidi Williams
All Responded
2026-0017 13 Jan 2026
Essex Police
Alcohol, drug and medication related deaths
Concerns summary Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the matter.
Action taken summary Essex Police has accepted the concerns and is now actively investigating the alleged drug supply issues through its Serious Violence Unit, with early analysis indicating a complex, multi-force, and po
Wendy Eyles
No Identified Response
2025-0641 22 Dec 2025
Northamptonshire Healthcare Foundation … Northamptonshire Integrated Care Board
Railway related deaths Suicide (from 2015)
Concerns summary No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.
Elaine Griffiths
All Responded
2026-0106 22 Dec 2025
Northampton General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Action taken summary The Trust has implemented electronic fluid balance charts on Nervecentre, updated food and fluid charts, and established monthly clinical skills sessions for staff. They are consistently recording all
Wendy Eyles
Response Pending
2026-0153 22 Dec 2025
Northamptonshire Integrated Care Board Northamptonshire Healthcare NHS Foundat…
Railway related deaths Suicide (from 2015)
Concerns summary A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to uncoordinated treatment.
Jack Brown
All Responded
2025-0593 18 Nov 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.
Action taken summary The Department clarifies that the CQC regulates care providers, not staffing agencies, but providers remain legally responsible for staff suitability. The Department has revised the Care Workforce Pat
Lewis Garfield
All Responded
2025-0547 28 Oct 2025
Department of Health and Social Care South Central Ambulance Service East Midlands Ambulance Service +1 more
Emergency services related deaths (2019 onwards)
Concerns summary Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Action taken summary EMAS's Incident Review Group has discussed the concerns, and they are now implementing dynamic strategic conveyance daily and proactively initiating rapid handover requests during high demand. They ar
Paul Appleby
All Responded
2025-0530 21 Oct 2025
Northamptonshire Healthcare Foundation …
Community health care and emergency services related deaths
Concerns summary The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential future deaths.
Action taken summary The Trust clarified the specific incident by explaining communication failures and stated that to mitigate future risks, they have reissued the Standard Operating Procedure to Saturday court operators
Alexander McCormack
All Responded
2025-0548 19 Oct 2025
Northamptonshire Police
Suicide (from 2015)
Concerns summary Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and investigation.
Action taken summary Northamptonshire Police are in the process of creating new training presentations for all ranks, including updated training for transferring Inspectors on COMPACT file handling. The Detective Superint
Stella LeClaire
No Identified Response
2025-0619 9 Oct 2025
Secretary of State for Health and Socia… Secretary of State for the Home Departm…
Suicide (from 2015)
Concerns summary The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
Linda Farmer
All Responded
2025-0169 4 Apr 2025
Northampton General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and risking future patient harm.
Jane Bennett
All Responded
2025-0074 6 Feb 2025
National Highways
Road (Highways Safety) related deaths
Concerns summary The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further accidents and fatalities without intervention.
Leslie Hurwood
All Responded
2025-0078 5 Feb 2025
NORTHAMPTON GENERAL HOSPITAL NHS TRUST
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct medication procedures.
Shaun Hall
All Responded
2025-0054 30 Jan 2025
Northamptonshire Healthcare Foundation …
Mental Health related deaths Suicide (from 2015)
Concerns summary The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing a serious safety failure.
Harry Dunn
All Responded
2024-0411 4 Jul 2024
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.
Harry Dunn
All Responded
2024-0412 4 Jul 2024
Ministry of Defence Ministry of Defence Police Foreign, Commonwealth & Development Off…
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current training's coverage of wrong-way driving risks.
Harry Dunn
Partially Responded
2024-0413 4 Jul 2024
Department of Health and Social Care Medicines and Healthcare products Regul…
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide timely pain relief and potentially delaying life-saving pre-hospital treatment.
Liam McCarlie
All Responded
2024-0337 24 Jun 2024
Northamptonshire Integrated Care Board East Midlands Ambulance Service NHS Tru…
Emergency services related deaths (2019 onwards) Suicide (from 2015)
Concerns summary Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Iona Buckingham
All Responded
2024-0023 12 Jan 2024
NHS Northamptonshire Integrated Care Bo… NHS England Northampton General Hospitals NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.
Jonathan McCarthy
Partially Responded
2023-0402 24 Oct 2023
Practice Plus Group Serco Ministry of Justice +1 more
State Custody related deaths
Concerns summary Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting medical care and safety during transfers.
Miss C
Historic (No Identified Response)
2023-0309 25 Aug 2023
Resuscitation Council UK Northampton General Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
Sean Heeney
All Responded
2023-0250Deceased 14 Jul 2023
HM Prison and Probation Service
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
David Levett
All Responded
2023-0121 18 Apr 2023
National Highways
Road (Highways Safety) related deaths
Concerns summary The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant safety risk for broken-down vehicles.
Benjamin Teague
All Responded
2023-0096Deceased 17 Mar 2023
National Highways
Road (Highways Safety) related deaths
Concerns summary The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway safety risk that requires urgent attention and repair from National Highways.