Suffolk

Coroner Area
Reports: 89 Earliest: Apr 2014 Latest: 11 Mar 2026

74% response rate (above 62% average).

Response Status
Responded 66 No Response 1 Historic 16 Pending 6
AI Classification
Action Taken 60%
Action Planned 40%
Noted 0%
Disputed 0%
Based on 5 classified responses
Top Categories
Hospital Death (Clinical Procedure… (31) Suicide (from 2015) (19) Mental Health related deaths (13) Alcohol, drug and medication relat… (11) Other related deaths (10)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East of England average: +19 reports · +8pp response rate
vs national average: +6 reports · +12pp response rate
89 results
Janette Palmer
Response Pending
2026-0140 11 Mar 2026
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
Terrence Frost
Response Pending
2026-0135 9 Mar 2026
East Suffolk & North Essex NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, causing dangerous delays in assessment.
Paul Thompson
Response Pending
2026-0066 6 Feb 2026
HM Prison Probation and reducing offending
Suicide (from 2015)
Concerns summary HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
Roger Smith
Response Pending
2026-0069 6 Feb 2026
West Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.
Georgia Scarff
Response Pending
2026-0057 4 Feb 2026
Royal Hospital School Department for Education
Road (Highways Safety) related deaths
Concerns summary School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent practices and risks.
Lauren Moret-Dell
Response Pending
2026-0059 4 Feb 2026
Suffolk and North East Essex Integrated… West Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.
Anthony Card
All Responded
2026-0068 7 Nov 2025
Suffolk County Council Suffolk Constabulary
Suicide (from 2015)
Concerns summary There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from informing future assessments and potentially vital support decisions.
Action taken summary Suffolk County Council clarifies that direct mental health provision is primarily an NHS responsibility, and they will not establish a new MASH pathway for medium risk mental health-only cases. Howeve
Catherine Moore
No Identified Response
2025-0486 25 Sep 2025
Secretary of State for Defence
Road (Highways Safety) related deaths
Concerns summary The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, risking vehicle safety.
Martin Collins
Partially Responded
2025-0497 17 Sep 2025
Minister of State for Prisons Probation and Reducing Reoffending
State Custody related deaths Suicide (from 2015)
Concerns summary The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Action taken summary HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to
Charlotte Alderson
All Responded
2025-0307 18 Jun 2025
Department of Health and Social Care
Community health care and emergency services related deaths Emergency services related deaths (2019 onwards)
Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Terence Colby
All Responded
2025-0310 18 Jun 2025
Alexandra & Crestview Surgeries
Community health care and emergency services related deaths
Concerns summary A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.
Kathleen Gregory
All Responded
2025-0408 18 Jun 2025
Beccles Medical Centre
Care Home Health related deaths
Concerns summary A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Pamela Brand
All Responded
2025-0534 18 Jun 2025
West Suffolk Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
Action taken summary The Trust has implemented new digital care planning, a safety alert learning bulletin, and specific documentation projects for fluid balance, thromboprophylaxis, and discharge summaries. Training on r
Sonia Sore
All Responded
2025-0305 17 Jun 2025
North Court Care Home – Maven Healthcare
Care Home Health related deaths
Concerns summary The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
David Bendell
All Responded
2025-0292 5 Jun 2025
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
Ruth Pingree
All Responded
2025-0177 8 Apr 2025
Communities and Local Government Home Office Ministry of Housing
Accident at Work and Health and Safety related deaths Other related deaths Product related deaths
Concerns summary Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Thomas Glover
All Responded
2025-0157 24 Mar 2025
British Society of Gastroenterology Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate patient care.
Brigitte Favre
All Responded
2025-0639 12 Feb 2025
Suffolk and North East Essex Integrated… West Suffolk Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking adverse outcomes.
Action taken summary West Suffolk NHS Foundation Trust has implemented a new Oncology discharge planning tool, launched in February 2026, to standardise communication and inform discharge decision-making. They are also ex
Kim Robinson
All Responded
2025-0055 31 Jan 2025
Department of Health and Social Care
Alcohol, drug and medication related deaths Suicide (from 2015)
Concerns summary The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Denise Johnson
All Responded
2025-0030 30 Dec 2024
East Suffolk and North Essex Foundation…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
Timothy De Boos
All Responded
2024-0691 13 Dec 2024
Department of Health and Social Care
Mental Health related deaths Suicide (from 2015)
Concerns summary A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.
Amy Butcher
All Responded
2024-0651 26 Nov 2024
Norfolk and Suffolk NHS Foundation Trust Department of Health and Social Care
Alcohol, drug and medication related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.
Erin Tillsley
All Responded
2024-0636 12 Nov 2024
Suffolk and North East Essex Integrated… West Suffolk NHS Foundation Trust
Child Death (from 2015) Mental Health related deaths Suicide (from 2015)
Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.
Brian Beer
All Responded
2024-0564 21 Oct 2024
National Institute of Health and Care E…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.
Nigel Hammond
All Responded
2024-0537 9 Oct 2024
Department of Health and Social Care Suffolk County Council Norfolk and Suffolk NHS Foundation Trust
Mental Health related deaths Suicide (from 2015)
Concerns summary An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.