Suffolk
Coroner Area
Reports: 89
Earliest: Apr 2014
Latest: 11 Mar 2026
74% response rate (above 62% average).
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
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.
Levi Cronin
Historic (No Identified Response)
2017-0287
6 Oct 2017
HMP Highpoint
State Custody related deaths
Concerns 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
The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding systemic failures or future death risks.
Steven Trudgill
Historic (No Identified Response)
2016-0210
6 Jun 2016
Ministry of Justice
State Custody related deaths
Suicide (from 2015)
Concerns 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
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.
Fiona Lewis
Historic (No Identified Response)
2015-0441
17 Sep 2015
Ipswich Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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
A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.
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
Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.
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
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.
Samuel Openshaw
Historic (No Identified Response)
2014-0280
20 Jun 2014
East Anglia Team
Coronary Heart Disease Review’s Clinica…
Congenital Heart Services Clinical Refe…
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Thomas Allen
Partially Responded
2014-0160
9 Apr 2014
Department for Environment
Suffolk Constabulary
Food and Rural Affairs
Road (Highways Safety) related deaths
Concerns 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.
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
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.
Paul Reynolds
All Responded
2021-0151
Other related deaths
Police related deaths
Concerns 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 taken summary
Britannia Jinky Jersey Ltd will remove all references to ground restraint from its Physical Intervention Policy and will re-emphasise that unbadged staff are not permitted to participate in restraint.
Paul Meadows
All Responded
2022-0201
Ipswich and East Suffolk Clinical Commi…
Department of Health and Social Care
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary
Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.
Action taken summary
NHS Suffolk and North East Essex has provided additional funding to increase NSFT service capacity, established a new clinical leadership post, and repurposed the First Response Service (FRS) to trans