City of Sunderland
Coroner Area
Reports: 50
Earliest: Sep 2013
Latest: 4 Mar 2026
74% response rate (above 62% average).
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.
Sheila Ross
Historic (No Identified Response)
2018-0081
19 Mar 2018
Hylton View Care Home
Care Home Health related deaths
Concerns summary
The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.
Raymond Davidson
Historic (No Identified Response)
2018-0059
27 Feb 2018
North East Ambulance Service NHS Trust
Community health care and emergency services related deaths
Concerns summary
Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
John Lambton
Historic (No Identified Response)
2018-0046
14 Feb 2018
Dairy Lane Care Centre
Care Home Health related deaths
Concerns summary
Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.
Derek Turnbull
Historic (No Identified Response)
2017-0076
16 Mar 2017
Gateshead Health Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.
Vincent Smith
Historic (No Identified Response)
2016-0134
6 Apr 2016
Village Nursing and Care Home
Care Home Health related deaths
Concerns summary
The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.
Melanie Amundsen
Historic (No Identified Response)
2015-0206
29 May 2015
Advisory
Conciliation and Arbitration Service
Other related deaths
Concerns summary
There is a lack of awareness among employers and employees regarding mental health issues in the workplace, particularly concerning disciplinary processes, suggesting ACAS guidance could be enhanced and better publicised.
Leonard Hudson
Historic (No Identified Response)
2014-0419
24 Sep 2014
City Hospitals Sunderland NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
Thomas Dixon
Historic (No Identified Response)
2014-0315
8 Jul 2014
City Hospitals Sunderland NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify these ongoing administrative issues affecting patient care.
James Stokoe
Historic (No Identified Response)
2014-0019
16 Jan 2014
Department of Health and Social Care
Mental Health related deaths
Concerns summary
Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.