Suffolk

Coroner Area
Reports: 93 Earliest: Apr 2014 Latest: 6 Apr 2026

77% response rate (above 63% average).

Response Status
Responded 72 No Response 4 Historic 16 Pending 1
AI Classification
Action Taken 35%
Action Planned 39%
Noted 26%
Disputed 0%
Based on 106 classified responses
Top Categories
Hospital Death (Clinical Procedure… (32) Suicide (from 2015) (20) 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: +22 reports · +9pp response rate
vs national average: +9 reports · +14pp response rate
93 results
Stephen Coombes
Partially Responded
2022-0229 25 Jul 2022
Kier Highways Ltd Suffolk Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to confusion for road users and police. This failure significantly increased the risk of collisions at a known road defect.
Action Taken (AI summary) Kier obscures existing speed limit signs and road markings when implementing temporary speed reductions, checks temporary traffic management daily, updated its WMS (Work Management System) to ensure checks are scheduled from the point of installation. They have also implemented an enhanced procedure with an audit program and provided enhanced guidance and toolbox talks to work gangs and completed a site investigation and options study of Burnt Fen Turnpike.
Ethan Wright
All Responded
2022-0226 25 Jul 2022
Suffolk Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary) A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a high collision risk, particularly for children.
Action Planned (AI summary) The council plans to install an illuminated 'STOP' sign, paint a white stop line, paint 'STOP' on the tarmac, and paint the existing concrete bollards with yellow and black paint. Installation is planned within 15 weeks.
Corrie McKeague
All Responded
2022-0097 1 Apr 2022
British Standards Institute, Container …
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) In effective bin locks and the absence of an automated weight flagging system failed to detect an individual in a bin, further compounded by poor driver visibility and inadequate search tools.
Noted (AI summary) CHEM notes the concerns raised regarding public entry into containers and will welcome suggestions for additional warnings for operators. Biffa is reviewing operating instructions to ensure clarity on the use of viewing windows, reminding customers about using locks effectively, and continuing to develop relationships with charities supporting rough sleepers. Dennis Eagle explains the design intent of the side window on their refuse vehicles, stating it's for viewing the discharge of container contents and not for viewing the floor of the tailgate. BSI consulted experts and will raise the issue of bin locks when the committee next meets to discuss if changes to existing standards are appropriate.
Colin Swain
Historic (No Identified Response)
2022-0076 10 Mar 2022
Priority Dispatch Corporation
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a need for clearer guidance on managing such scenarios.
Victoria Harrild-Jones
All Responded
2021-0386 17 Nov 2021
Ministry of Defence
Other related deaths Service Personnel related deaths
Concerns summary (AI summary) Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Action Planned (AI summary) The Defence Professor of General Practice has committed to add this case and reflective discussion to the mandatory course for all Defence GP trainees held in Cyprus each June. The DMS Overseas Assurance Working Group is reviewing the assurance process to create supporting policy and a common framework.
Joshua Sahota
All Responded
2021-0301 9 Sep 2021
Department of Health and Social Care Hellesdon Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.
Noted (AI summary) Hellesdon Hospital has implemented a complete ban on plastic bags, improved communication to families and carers, and put safeguards in place to disrupt the passage of restricted items. The Department of Health and Social Care acknowledges the concerns, mentions actions taken by the Norfolk and Suffolk NHS Foundation Trust, points to a safety alert published in 2011, and outlines progress in reducing suicides.
Thomas Pickering
All Responded
2021-0289 20 Aug 2021
National Highways Suffolk Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary) The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk of future road traffic collisions at the site.
Noted (AI summary) Suffolk County Council Highways has assessed the report and agreed to install a pair of hidden dip signs north of the Wallers Farm access, facing southbound traffic and will now proceed to design suitable locations, leading to the erection of new posts and signs in due course. National Highways states that they are not responsible for the A137 and cannot comment, advising the coroner to contact Suffolk County Council instead.
Roland Stannard
All Responded
2021-0274 17 Aug 2021
Department of Health and Social Care
Care Home Health related deaths
Concerns summary (AI summary) Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate assessment for nursing care needs.
Noted (AI summary) The Minister acknowledges the concerns and outlines the responsibilities of CQC registered providers regarding staff training and care delivery. It also mentions NHS England support for care homes and the upcoming statutory inquiry into the Government’s response to the Covid-19 pandemic.
Paul Reynolds
All Responded
2021-0151
Brittania Jinky Jersey Limited Brittania Hotels Group Limited
Other related deaths Police related deaths
Concerns summary (AI summary) Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.
Action Planned (AI summary) The company is planning to remove ground restraint references from its Physical Intervention Policy and re-emphasise that non-badged staff are not permitted to participate in restraint. It is also investigating engaging external providers for annual refresher security training. Suffolk Constabulary has enhanced its training delivery and supporting guidance on officer assessments and use of force, and invested in a new skills management system to track training records. It is also reviewing training schedules and designing new scenarios for scene management.
Andrew Gibbins
All Responded
2020-0290 17 Dec 2020
West Suffolk Hospital and The Wedgewood…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.
Action Taken (AI summary) The Trusts have commenced monthly meetings between the head of mental health and the lead nurse, and reviewed the handover process, incorporating SBAR documentation into the WSFT risk assessment. The acute hospital missing person’s policy has been reviewed and deemed fit for purpose in January 2021. Hellesdon Hospital reports that they have established regular interface meetings with the West Suffolk Hospital to improve communication and have formalized these meetings with agreed actions and minutes for governance purposes.
Karen Jane Winn
All Responded
2020-0213 22 Oct 2020
West Suffolk Hospital
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.
Action Planned (AI summary) A flow pathway for Autoimmune Haemolytic Anaemia has been established and published in the Trust’s ‘Pink Book’ and will be included in the ‘Heads Up book’ (HUB), which is currently under development. The VTE assessment tool will be updated to include a prompt for haemolytic anaemia.
Piotr Kierzkowski
All Responded
2020-0204 12 Oct 2020
Department of Health and Social Care
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.
Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has increased capacity through the opening of four crisis house beds in Norwich, with plans to open two additional crisis houses in the coming months, as well as extra ward capacity for older people. The Trust has reviewed its bed management processes to ensure clinically-led admissions.
May Miller
All Responded
2020-0201 8 Oct 2020
Suffolk Safeguarding Partnership Limes Sheltered Housing
Care Home Health related deaths Mental Health related deaths
Concerns summary (AI summary) Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of inter-agency sharing.
Action Planned (AI summary) The Limes will contact receiving care homes to share information when a resident is considering a move. They will also invite local Social Services and GP practice to coffee mornings to build a working relationship. Suffolk County Council is undertaking a Safeguarding Adults Review, with themed learning points to be defined. The review is expected to be completed by mid-December 2020, with full sign off by the SAB in February 2021.
Susan Warby
All Responded
2020-0188 25 Sep 2020
Department of Health and Social Care Medicines and Healthcare Products Regul…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.
Action Planned (AI summary) The MHRA will consider with the marketing authorisation holder whether improvements could be made to assist clinical staff to more easily assimilate the statutory information on intravenous fluid bags to reduce the likelihood of errors. West Suffolk NHS Foundation Trust implemented enhanced procedures and safeguards, including more robust processes for prescribing and checking fluid bags, introducing clear medication bags, and altering medication bag displays. They have seen a reduction in intensive care medication errors as a result.
Darren King
Historic (No Identified Response)
2020-0090 6 Apr 2020
Adult and Community Services Suffolk Co… Norfolk and Suffolk NHS Foundation Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Jamie Finlay
All Responded
2019-0510 17 Dec 2019
Transport and Rural Affairs at Suffolk …
Road (Highways Safety) related deaths
Concerns summary (AI summary) The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.
Action Planned (AI summary) Suffolk County Council will review the junction design and layout to identify engineering solutions to reduce the opportunity for drivers to turn right in advance of the centre island, and will continue to monitor collisions across the county.
Matthew Fitten
All Responded
2020-0275 7 Dec 2019
Public Health England, General Pharmace…
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.
Noted (AI summary) Haverhill Pharmacy continues to supply methadone in individual containers, in line with normal working procedures. The pharmacy will make prescribers aware in advance if it faces any issues. PHE provides context on its COVID-19 guidance to the drug and alcohol treatment sector, developed with sector representatives. They emphasize the need for individualised risk assessments before changing medication dispensing arrangements and that the CQC is monitoring these changes.
Gemma Macdonald
Partially Responded
2019-0417 5 Dec 2019
1st For Health International; StockXS L… Medicines and Healthcare products Regul…
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about online access to medicines and outlines existing regulations and initiatives to improve patient safety, including the Falsified Medicines Directive and Local Health and Care Record Exemplars.
Deborah Headspeath
All Responded
2019-0387 18 Nov 2019
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary (AI summary) There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory guidance for pharmacists on online prescriptions lacks mandatory adherence and clear sanctions.
Action Taken (AI summary) The Department of Health and Social Care is working with the CQC and regulators to better regulate online prescribers. Measures already taken include co-authoring principles of good practice in remote consultations, commissioning a review of overprescribing, and asking NICE to develop guidance on safe prescribing of dependence-associated drugs.
Mark Jarvis
Historic (No Identified Response)
2019-0304 19 Sep 2019
NHS England SystemOne TPP Ltd
State Custody related deaths
Concerns summary (AI summary) The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Oliver Hall
All Responded
2019-0198 17 Jun 2019
Association of Ambulance East of England Ambulance Service N.I.C.E
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.
Action Planned (AI summary) AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission.
Kerry Hunter
All Responded
2019-0137 23 Apr 2019
Norfolk & Suffolk NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.
Action Planned (AI summary) The Trust is implementing a new Personality Disorder Service with a phased approach, including needs-based interventions, crisis support, peer support workers, and training for all staff, with regular review points to assess impact and adjust the service as needed. The Trust has co-produced patient-facing information, is reviewing its personality disorders strategy, has rolled out a training program, upskilled community teams, and is supporting MHPs to offer evidence-informed approaches, and is recruiting a specialist post and setting up a working group to provide for people with comorbid ASD and personality disorder.
Anthony Buckingham
All Responded
2019-0123 9 Apr 2019
Norfolk and Suffolk NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.
Action Taken (AI summary) The Trust's suicide prevention lead has hosted two events bringing together non-statutory and statutory agencies, service users and Trust services in order to open channels of communication and raise awareness what each other provides. The Trust is strengthening its clinical and service leadership to ensure have the necessary breadth of skills and resource to lead safe and effective services.
Justin Brown
Historic (No Identified Response)
2019-0103 27 Mar 2019
Suffolk County Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were not effectively monitored for vulnerable patients.
Mohammed Ahmed
Partially Responded
2019-0093 19 Mar 2019
Department of Health and Social Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug interactions and side effects with Olanzapine.
Noted (AI summary) The Department of Health acknowledges the concerns but states that the MHRA considers current warnings for olanzapine to be adequate and will keep the issue under scrutiny. NHS England will encourage medical directors to remind prescribers of the risks highlighted within the SPC when prescribing antipsychotic medication to people who are known users of synthetic cannabinoids.