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
Jeremy Sutch
Partially Responded
2019-0065 22 Feb 2019
International Maritime Organisation Vantage Drilling Company
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a risk for future survivable injuries.
Action Taken (AI summary) Vantage Drilling Company updated its HSE Manual to include reference to different stretcher types. They also added 'Drill Medivac Chair Type Stretcher' to the Emergency Response Drill Matrix, requiring drills every six months, and updated the Rig Specific Emergency Response Manual to detail different stretcher types.
Mark Harris
Historic (No Identified Response)
2019-0023 17 Jan 2019
Emergency Operation Centre Norwich Melbourne Ambulance Station
Emergency services related deaths (2019 onwards) Mental Health related deaths
Concerns summary (AI summary) Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.
Matthew Arkle
All Responded
2018-0361 13 Nov 2018
Norfolk and Suffolk NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.
Action Taken (AI summary) The Trust issued an internal alert to inpatient wards directing reflection on points where information is received from external sources. It also referenced the Trust policy on Missing Persons and Failure to return from Leave created with Norfolk and Suffolk Police and published in May 2017.
Canon Frost
Partially Responded
2018-0362 3 Oct 2018
East Coast Community Healthcare Team Head of the Roman Catholic Church of En… The Diocese of Westminster
Other related deaths
Concerns summary (AI summary) Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Action Planned (AI summary) The Diocese will conduct annual property and safety assessments for retired priests, involving a surveyor, welfare officer, and the priest. Necessary repairs will be organised and paid for by the Diocese, with escalation procedures for disagreements.
Brian Frost
Historic (No Identified Response)
2018-0332 3 Oct 2018
Diocese of Westminster the Roman Catholic Church of England an… Patrick Stead Hospital
Community health care and emergency services related deaths
Concerns summary (AI summary) Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Ashley Notson
Historic (No Identified Response)
2018-0207 29 Jun 2018
Care Quality Commission Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.
Daphne Penn
Historic (No Identified Response)
2018-0206 29 Jun 2018
Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Levi Cronin
Historic (No Identified Response)
2017-0287 6 Oct 2017
HMP Highpoint HM Prison and Probation Service NHS England
State Custody related deaths
Concerns summary (AI summary) Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
Rachel Edwards
All Responded
2024-0220 27 Feb 2017
Norfolk and Suffolk NHS Foundation Trust
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The report notes Rachel was informally admitted.
Action Planned (AI summary) The Trust will assess medications prescribed upon discharge, which will continue across the Trust. The Trust is planning the technical changes required to build electronic bridges between different elements of the health system, but there is no confirmed date for completion.
Steven Trudgill
Historic (No Identified Response)
2016-0210 6 Jun 2016
Ministry of Justice
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Archie Hall
All Responded
2016-0495 12 May 2016
Suffolk County Council Highway Departme…
Road (Highways Safety) related deaths
Concerns summary (AI summary) The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a significant risk of falls that has led to multiple deaths.
Action Planned (AI summary) Highways England commissioned a review of preventative measures for suicides on the Orwell Bridge and are reviewing the effectiveness of the telephones located at either end of the bridge, and will implement changes at the earliest opportunity. They are not intending to take further action regarding toe holds on the outer face of the bridge.
Fiona Lewis
Historic (No Identified Response)
2015-0441 17 Sep 2015
Ipswich Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.
Anthony Cleveland
Historic (No Identified Response)
2015-0442 14 Sep 2015
Health and Safety Executive
Other related deaths
Concerns summary (AI summary) A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.
Samuel Openshaw
Historic (No Identified Response)
2014-0280 20 Jun 2014
Congenital Heart Services Clinical Refe… Coronary Heart Disease Review Coronary Heart Disease Review’s Clinica… +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.
Redmond Johnson
Historic (No Identified Response)
2014-0279 20 Jun 2014
Ministry of Justice NHS England
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
Else Harvey-Samuel
Historic (No Identified Response)
2014-0278 20 Jun 2014
West Suffolk Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.
Thomas Allen
Partially Responded
2014-0160 9 Apr 2014
Department for Environment, Food and Ru… Suffolk Constabulary
Road (Highways Safety) related deaths
Concerns summary (AI summary) The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary police/local authority protocol is not yet in force.
Noted (AI summary) Defra acknowledges the concerns regarding fly-grazing and the death of Thomas Allen, but states that existing legislation (Highways Act 1980, Animals Act 1971, Anti-social Behaviour, Crime and Policing Act 2014) is already in place to tackle the issue. They are encouraging joint working amongst authorities and monitoring the situation in Wales.
Jamie Barlow
Historic (No Identified Response)
2014-0153 7 Apr 2014
Norfolk and Suffolk NHS Foundation Trust Suffolk Constabulary
Community health care and emergency services related deaths
Concerns summary (AI summary) There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.