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 71%
Action Planned 14%
Noted 14%
Disputed 0%
Based on 21 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
Clear 31 results
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
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
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
University Hospitals of Northamptonshire Department of Health and Social Care South Central 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
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.
Action taken summary The Trust has established a robust process for reviewing all Structured Judgement Review (SJR) outcomes in a weekly MDT meeting with tracked actions. The specific case was discussed in the …
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.
Action taken summary National Highways is planning minor surfacing works for Summer 2025, including refreshing road markings and reflective studs, and investigating vegetation clearance. A major A43 renewals scheme, inclu
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.
Action taken summary The Trust immediately reinforced insulin administration practices through ward visits, created and used dedicated huddle sheets, and conducted an audit of insulin patients. They have established an In
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.
Action taken summary Northamptonshire Healthcare Foundation Trust has emphasized record-keeping standards to UCAT staff and developed a new audit tool. They have also enabled full visibility of patient records between UCA
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.
Action taken summary The DHSC Minister of State for Health has ordered a full independent investigation into NHS performance, with findings to inform a 10-year reform plan. They are maintaining increased ambulance capacit
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.
Action taken summary The government has received assurances from US authorities that driver training for US Visiting Forces and diplomats includes a focus on driving on the left. The FCDO has also written …
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.
Action taken summary Northamptonshire ICB and NHFT, working with EMAS, implemented a 24/7 mental health crisis service in late 2023, providing ambulance service access to mental health practitioners within an hour. EMAS i
Iona Buckingham
All Responded
2024-0023 12 Jan 2024
Northampton General Hospitals NHS Trust NHS England NHS Northamptonshire Integrated Care Bo…
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.
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.
Jack Knapman
All Responded
2022-0405 16 Dec 2022
Home Office
Alcohol, drug and medication related deaths
Concerns summary Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human consumption, risking further deaths.
Alfie Stone
All Responded
2022-0013 14 Jan 2022
East Midlands Ambulance Service
Child Death (from 2015) Emergency services related deaths (2019 onwards)
Concerns summary Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
Andrew Cook
All Responded
2021-0258 18 Jun 2021
Medicines and Healthcare products Regul…
Alcohol, drug and medication related deaths Product related deaths
Concerns summary Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, and various synonyms.
Mohan Acharya
All Responded
2020-0045 27 Feb 2020
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately 500 deaths annually.
Susan Sterland
All Responded
2020-0062 28 Jan 2020
Kettering General Hospital NHS Foundati…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying critical diagnosis of an obstruction.
Blaithin Buckley
All Responded
2019-0465 16 Sep 2019
General Council
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
Diana Gudgeon
All Responded
2019-0015 9 Jan 2019
111 Service East Midlands Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.
David Chandler
All Responded
2018-0215 5 Jul 2018
Carlsberg Supply Co Ltd
Accident at Work and Health and Safety related deaths
Concerns summary An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between contractors for safe isolation.