City of Sunderland

Coroner Area
Reports: 50 Earliest: Sep 2013 Latest: 4 Mar 2026

74% response rate (above 62% average).

Response Status
Responded 37 Historic 10 Pending 1
AI Classification
Action Taken 62%
Action Planned 23%
Noted 8%
Disputed 8%
Based on 13 classified responses
Top Categories
Hospital Death (Clinical Procedure… (20) Care Home Health related deaths (7) Mental Health related deaths (6) Other related deaths (6) Community health care and emergenc… (5)
Quarterly Trend
Category Breakdown
How does this area compare?
vs North East average: +7 reports · +9pp response rate
vs national average: -33 reports · +12pp response rate
50 results
Oriel Vasey
Response Pending
2026-0124 4 Mar 2026
NHS North East and North Cumbria Integr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with a risk of recurrence as the process remains unaddressed.
Avery Hall
Response Pending
2026-0048 2 Feb 2026
Royal College of General Practitioners Riverview Surgery
Child Death (from 2015)
Concerns summary A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, risking foetal harm.
Action taken summary Riverview Surgery has implemented a new Standard Operating Protocol for prescribing medication to women of child-bearing age, which includes counselling patients and stopping contraindicated medicatio
Valerie Gibson
All Responded
2025-0630 17 Dec 2025
Cumbria, Northumberland, Tyne and Wear …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Action taken summary The Trust has completed comprehensive training for all nursing staff and amended its Medicine’s Management Policy to ensure medication is dispensed before administration. They have also updated e-lear
Thompson Elliott
All Responded
2025-0515 14 Oct 2025
Care UK
Care Home Health related deaths
Concerns summary Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Action taken summary Care UK has conducted extensive staff discussions and reminded all care homes of internal policies on discharge information and handover procedures. The Grangewood care home has updated its contact do
Anne Dyson
All Responded
2025-0439 26 Aug 2025
South Tyneside and Sunderland NHS Found…
Community health care and emergency services related deaths
Concerns summary Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
Action taken summary The Trust has shared learning with radiologists regarding search extent and confirmation bias, and is developing updated induction training, a work instruction, and a Standard Operating Procedure (SOP
Joel Ineson
All Responded
2025-0183 10 Apr 2025
Department for Culture, Media and Sport Health and Safety Executive
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Action taken summary The Department for Culture, Media and Sport acknowledges existing initiatives like the 'Beyond Swim' accreditation scheme and Swim England's new open water swimming leader training course. The Ministe
Allan Taylor
All Responded
2025-0138 11 Mar 2025
South Tyneside and Sunderland NHS Found…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. This lack of escalation and compliance likely contributed to an unwitnessed fall.
Action taken summary The Trust conducted an urgent review and has amended its EICO guideline, renaming it Enhanced Therapeutic Observation and Care (ETOC). The new guideline clarifies observation levels, assessment, escal
Jack Shields
All Responded
2025-0122 4 Mar 2025
Nerams Group
Emergency services related deaths (2019 onwards)
Concerns summary An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.
Action taken summary The Nerams Group dismissed the senior clinician for gross negligence and a second employee for unrelated employment reasons following the incident. They have also implemented refreshed competency asse
John Hurst
All Responded
2024-0568 23 Oct 2024
Cumbria, Northumberland, Tyne and Wear … Northumbria Police
Mental Health related deaths Police related deaths Suicide (from 2015)
Concerns summary Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.
Action taken summary Northumbria Police has provided appropriate instruction and learning to custody staff through the Force Custody Newsletter, the Custody Compendium, and direct reminders to Custody Sergeants, emphasizi
Jason Brown
All Responded
2024-0133 12 Mar 2024
National Pharmacy Association Medicines and Healthcare Products Regul… General Pharmaceutical Council +1 more
Suicide (from 2015)
Concerns summary Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.
Mason French
All Responded
2023-0208 22 Jun 2023
South Tyneside Council
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.
Daniel Futers
All Responded
2023-0040Deceased 2 Feb 2023
Cumbria, Northumberland, Tyne and Wear …
Suicide (from 2015)
Concerns summary Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.
Charlotte Warkcup
All Responded
2022-0301 29 Sep 2022
Department of Health and Social Care
Child Death (from 2015) Community health care and emergency services related deaths
Concerns summary Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.
Alan Hodgson
Historic (No Identified Response)
2022-0067 3 Mar 2022
County Durham and Darlington NHS Founda…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.
Brendan Eccles
Partially Responded
2022-0007 10 Jan 2022
EKO-INVEST POM-EKO and EURO-EKO
Accident at Work and Health and Safety related deaths
Concerns summary Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a significant explosion risk.
Vinnie Dodds
All Responded
2021-0249 20 Jul 2021
Department of Health and Social Care
Child Death (from 2015)
Concerns summary There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia lacks clarity on rare risks of foetal or maternal death.
Daniel Rennoldson
All Responded
2021-0206 17 Jun 2021
Cumbria, Northumberland, Tyne and Wear …
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.
Richard Burgess
All Responded
2021-0163 19 May 2021
Cumbria, Northumberland, Tyne and Wear … Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.
Sheldon Farnell
All Responded
2021-0081 25 Mar 2021
Department of Health and Social Care
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Edward Mallaby
All Responded
2020-0277 10 Dec 2020
Alexandra View Care Home
Care Home Health related deaths
Concerns summary The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.
Gary Sloan
All Responded
2020-0009 22 Jan 2020
Sunderland City Council
Road (Highways Safety) related deaths
Concerns summary A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety restrictions and drainage.
Kay Martin
All Responded
2019-0262 27 Aug 2019
Home Office
Other related deaths
Concerns summary A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.
Nguyen Quyen
All Responded
2019-0194 12 Jun 2019
National Probation Service
Other related deaths
Concerns summary A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with inadequate monitoring and challenges to deceit.
Thomas Collings
All Responded
2019-0260 15 Apr 2019
GE Healthcare South Tyneside and Sunderland NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.
James McLaren
All Responded
2018-0330 4 Oct 2018
Chartered Institution of Waste Manageme… Environmental Services Associations Health and Safety Executive +1 more
Other related deaths
Concerns summary Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.