Suffolk

Coroner Area
Reports: 89 Earliest: Apr 2014 Latest: 11 Mar 2026

74% response rate (above 62% average).

Response Status
Responded 66 No Response 1 Historic 16 Pending 6
AI Classification
Action Taken 60%
Action Planned 40%
Noted 0%
Disputed 0%
Based on 5 classified responses
Top Categories
Hospital Death (Clinical Procedure… (31) Suicide (from 2015) (19) 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: +19 reports · +8pp response rate
vs national average: +6 reports · +12pp response rate
Clear 16 results
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 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.
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 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.
Mark Jarvis
Historic (No Identified Response)
2019-0304 19 Sep 2019
NHS England SystemOne TPP Ltd
State Custody related deaths
Concerns 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.
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 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.
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 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.
Brian Frost
Historic (No Identified Response)
2018-0332 3 Oct 2018
Diocese of Westminster Patrick Stead Hospital
Community health care and emergency services related deaths
Concerns 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.
Daphne Penn
Historic (No Identified Response)
2018-0206 29 Jun 2018
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 Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
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.
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.
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
NHS England Ministry of Justice
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
Congenital Heart Services Clinical Refe… East Anglia Team Coronary Heart Disease Review +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.
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.