Suffolk
Coroner Area
Reports: 89
Earliest: Apr 2014
Latest: 11 Mar 2026
74% response rate (above 62% average).
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.
Action taken summary
The Department of Health and Social Care notes that NHS England has no current plans for guidance on a single infection scoring system. It highlights ongoing research funding for sepsis …
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.
Action taken summary
Mr. Colby's doctor reflects on the consultation and the expert's report, acknowledging missed opportunities. The doctor states they have learned from the case through reflection and reading guidelines
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.
Action taken summary
Beccles Medical Centre plans a significant event analysis of this case focusing on ReSPECT form completion and wording, scheduled for 4 September 2025. They will also conduct a practice-level review …
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.
Action taken summary
Maven Healthcare has restructured its clinical governance framework, established a corporate committee, and implemented a new audit program with weekly falls audit tools. They have delivered staff tra
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.
Action taken summary
The DHSC highlights that Suffolk and North East Essex (SNEE) ICS will reinforce with multidisciplinary teams the importance of reassessing patient needs, and their Neuro Rehabilitation Programme Group
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.
Action taken summary
The Government has enhanced the legal status of fire safety guidance through the Building Safety Act and introduced new regulations requiring fire risk assessments to be recorded in all cases, …
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.
Action taken summary
The Society acknowledges the concerns about clinician awareness and patient information regarding hiatus hernias. Although they have no current published guidance, they will work with Guts UK to devel
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.
Action taken summary
The DHSC acknowledged concerns regarding the online prescribing system, referencing existing General Pharmaceutical Council guidance and broader government commitments to suicide prevention and mental
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.
Action taken summary
East Suffolk and North Essex Foundation Trust has started three-monthly ERCP Multi-Disciplinary Team meetings to discuss cases and complications. They have also drafted and approved a new cross-site S
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.
Action taken summary
DHSC has published national guidance on the management of mental health patients in Emergency Departments (December 2023) and statutory guidance on discharge from mental health inpatient settings (Jan
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.
Action taken summary
Norfolk and Suffolk NHS Trust has implemented a new Standard Operating Procedure for its mental health liaison teams within acute hospitals to clearly outline aims and expectations. They have also …
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.
Action taken summary
West Suffolk NHS Foundation Trust has already reviewed and updated ED processes and training for self-harm patients, including revising triage forms and implementing a daily Mental Health Safety Huddl
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.
Action taken summary
NICE disputes the premise that its guidelines on anti-coagulation after hip fracture surgery are outdated, stating they are not aware of evolving international consensus on prophylaxis length for the
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.
Action taken summary
Norfolk and Suffolk NHS Foundation Trust, in collaboration with Suffolk County Council, has produced and agreed a new guidance document clarifying the process for Approved Mental Health Professionals