Suffolk
Coroner Area
Reports: 93
Earliest: Apr 2014
Latest: 6 Apr 2026
77% response rate (above 63% average).
Allan Stevenson
Response Pending
2026-0207
6 Apr 2026
Anglican Water
Core Highways Group Limited
Secretary of State for Transport
+1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was unavailable due to the plan flip.
Peter Pettit
No Identified Response
2026-0196
2 Apr 2026
Multi-Care Community Services Suffolk
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies had not been addressed.
David Abbot
No Identified Response
2026-0195
2 Apr 2026
West Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of a DVT; additionally, concerns were raised about ineffective communication processes between hospital staff and patients.
Melanie Pinnell
All Responded
2026-0185
26 Mar 2026
Unity Healthcare
Suicide (from 2015)
Concerns summary (AI summary)
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline was not actioned by a GP, posing a risk to patient safety.
Action Taken
(AI summary)
• Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF).
• The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework.
Janette Palmer
All Responded
2026-0140
11 Mar 2026
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
1 response
from Department of Health and Social Care
Terrence Frost
All Responded
2026-0135
9 Mar 2026
East Suffolk & North Essex NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
• The Trust implemented a new electronic patient record system in October 2025.
• This system allows internal users to send secure messages to each other on patient records, creating a new line of communication internally.
• This has reduced the pressure for response from the medical team for the Medical Assessment Unit by providing an alternative means of communication for internal users.
Roger Smith
All Responded
2026-0069
6 Feb 2026
West Suffolk NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
1 response
from West Suffolk NHS Foundation Trust
Paul Thompson
All Responded
2026-0066
6 Feb 2026
HM Prison, Probation and reducing offen…
Suicide (from 2015)
Concerns summary (AI 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.
1 response
from HMP Norwich
Lauren Moret-Dell
All Responded
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 (AI 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.
Action Taken
(AI summary)
• The Stroke team at WSFT immediately contacted the responsible medical team to clarify the correct TIA referral process with them.
• The Trust has updated the TIA referral guideline to improve clarity around the process.
Georgia Scarff
No Identified Response
2026-0057
4 Feb 2026
Department for Education
Minister for Women and Equalities
Royal Hospital School
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Anthony Card
All Responded
2026-0068
7 Nov 2025
Suffolk Constabulary
Suffolk County Council
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
Suffolk County Council acknowledges the report but clarifies that the responsibility for adult mental health provision rests with NHS commissioners and providers. It states its role is concerned with statutory functions under the Care Act, including safeguarding and social care assessment. Suffolk Constabulary is committed to improving awareness and training for frontline staff in relation to adult mental health. Planned actions include vulnerability training scheduled for Autumn/Winter 2026 and participation in a multi-agency audit of NHS 111 Option 2.
Catherine Moore
No Identified Response
2025-0486
25 Sep 2025
Secretary of State for Defence
Road (Highways Safety) related deaths
Concerns summary (AI 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
All Responded
2025-0497
17 Sep 2025
Minister of State for Prisons, Probatio…
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI 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 Planned
(AI summary)
HMPPS has initiated discussions with BT to explore the feasibility of monitoring call volumes as a potential indicator of heightened suicide/self-harm risk as part of an ongoing development project. They emphasize that any technical solution would be an additional tool to their existing holistic approach, including ACCT and the Listener scheme.
Pamela Brand
All Responded
2025-0534
18 Jun 2025
West Suffolk Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
(AI summary)
The Trust highlights improvements in record keeping and communication, including safety alert learning bulletin emphasizing clear documentation, specific documentation projects to improve fluid balance measurement, thromboprophylaxis and discharge summaries. There are also plans for junior doctors to conduct a VTE treatment audit.
Kathleen Gregory
All Responded
2025-0408
18 Jun 2025
Beccles Medical Centre
Care Home Health related deaths
Concerns summary (AI summary)
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Action Planned
(AI summary)
The medical centre will conduct a significant event analysis of the case focusing on the RESPECT form completion and wording and then disseminate the findings to the practice team. The practice will also conduct a practice-level review of the training given to clinicians on the completion of RESPECT forms and further training for clinical staff on the management of choking situations has been arranged.
Terence Colby
All Responded
2025-0310
18 Jun 2025
Alexandra & Crestview Surgeries
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The doctor reflects on the consultation, acknowledges the concerns raised, and outlines their understanding of critical limb ischaemia and its management. They state that they will continue to stay updated reinforcing knowledge and learning. The surgeries plan to hold a learning event to review the presentation of patients with peripheral vascular disease and differential diagnosis of ‘foot and lower limb pain’. They will also review the presentation and management of similar lower limb pain, possible ischaemia, in weekly clinical meetings.
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 (AI 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.
Action Planned
(AI summary)
The Department of Health and Social Care notes the concerns and outlines ongoing research into sepsis diagnostics and management, and states that NHS England will be undertaking a review of existing guidance relating to the use of the FeverPAIN and Centor scoring systems. The manual transfer of information from 111 to 999 mitigates the risk associated with Interoperability toolkit (ITK) system failure.
Sonia Sore
All Responded
2025-0305
17 Jun 2025
North Court Care Home – Maven Healthcare
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Maven Healthcare has implemented mandatory post-incident debriefing, created an organizational lesson learned document, and reviewed policies/procedures for bed rails and falls risk management, and implemented an electronic care planning system. Staff refresher training on falls prevention was completed in January 2025, and electronic care planning was implemented in January 2025 and fully embedded by the end of March 2025.
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 (AI 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.
Action Planned
(AI summary)
SNEE ICS will work to reinforce the importance of MDT reassessments of patient needs with their multidisciplinary teams. The SNEE ICS Neuro Rehabilitation Programme Group will develop and review a strategic action plan to guide future commissioning of rehabilitation pathways within SNEE.
Ruth Pingree
Partially Responded
2025-0177
8 Apr 2025
Home Office
Ministry of Housing, Communities and Lo…
Accident at Work and Health and Safety related deaths
Other related deaths
Product related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
The Ministry of Housing, Communities & Local Government has enhanced guidance to Responsible Persons through Section 156 of the Building Safety Act, ensuring courts consider it in breach of FSO proceedings. They have issued new fire safety guidance for small paying guest accommodation, including caravans, which requires that all findings from fire risk assessments be recorded.
Thomas Glover
All Responded
2025-0157
24 Mar 2025
Department of Health and Social Care
British Society of Gastroenterology
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The BSG will work with Guts UK to develop a patient information leaflet for hiatus hernia, highlighting the need for extra vigilance following diagnosis of a para-oesophageal hernia. The DHSC acknowledges the concerns and explains that NHS England is responsible for providing information on NHS.UK, which is not designed for specialist clinical education or to raise awareness of conditions among the medical community, and CPD is the responsibility of the individual doctor.
Brigitte Favre
All Responded
2025-0639
12 Feb 2025
West Suffolk Hospital, Suffolk and Nort…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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
(AI summary)
The hospital clarified out-of-hours oncology telephone advice service availability and is implementing improved handover protocols, including a new electronic discharge summary to be piloted. The ED Governance Lead confirmed discharge letters are available to ED clinicians and are referenced to guide clinical decision making.
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 (AI 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.
Action Taken
(AI summary)
DHSC references existing GPhC guidance regarding remote consultations and verifying information to support prescribing decisions, noting that the GPhC is strengthening its guidance and expectations for pharmacy professionals providing remote services. The 8,500 new mental health workers we will recruit will be trained to support people at risk to reduce the lives lost to suicide.
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 (AI 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.
Action Taken
(AI summary)
The Trust is starting 3 monthly ERCP Multi-Disciplinary Team meetings to discuss all cases and complications. A cross-site SOP has been drafted and approved entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant”. The Trust is also implementing changes to ensure a named Consultant is allocated to patients.
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 (AI 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.
Action Planned
(AI summary)
The Department notes the concerns about mental health bed availability and communication between teams. The Trust is implementing weekly MADE events to support discharge, maximising staff availability for crisis team referrals, and planning a transformation of urgent care pathways in 2025.