Surrey
Coroner Area
Reports: 189
Earliest: Aug 2013
Latest: 10 Apr 2026
77% response rate (above 63% average).
Charne Petit
All Responded
2024-0514
26 Sep 2024
NHS England
Surrey and Borders Partnership Trust
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.
Noted
(AI summary)
The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level. NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care.
Helen Kerr
All Responded
2024-0498
18 Sep 2024
Surrey and Borders Partnership
Surrey County Council
Surrey Police
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health services out-of-hours is inadequate, and risks to staff from patients' delusions were not addressed.
Noted
(AI summary)
Surrey Council explains that the SCARF process is not designed for emergency referrals and that a clear process exists for officers to contact the Emergency Duty Team out of hours. The Trust updated its website with referral routes, enhanced collaboration with families, and revised the SBAR tool to include carer/family views. They have also implemented mandatory training for staff on the referral pathway to mental health services, with 86% completion to date and the remainder scheduled for completion soon. Surrey Police is reminding all officers to undertake research as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves; this message will be conveyed via force emails and a reminder on the daily briefing to response officers.
Philip Ross
All Responded
2024-0492
16 Sep 2024
South East Coast Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.
Action Taken
(AI summary)
South East Coast Ambulance Service has been working collaboratively to optimise the use of Urgent Community Response (UCR) Teams across the region since February 2024, and has introduced Clinical Validation Paramedics and Pharmacists to work in control rooms focusing on the clinical validation of 999 calls.
Paul Batchelor
All Responded
2024-0494
13 Sep 2024
Care Quality Commission
Medicines and Healthcare Products Regul…
Red House (Ashtead) Limited
Care Home Health related deaths
Product related deaths
Concerns summary (AI summary)
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.
Action Taken
(AI summary)
The MHRA highlights a National Patient Safety Alert published two months after the death with general requirements to prevent entrapment with beds and associated devices. They have also discussed with NAMDET the possibility of producing training materials for users of beds and bed rails, and the risks relating to entrapment, with a view to be available in the coming months. The care home has reinforced learnings, extended the Room Call Policy, implemented QR codes for night checks, and provided further training. The staff member involved is no longer working at the Red House. The CQC will continue to monitor the care home, utilising insight data and information from stakeholders. They have commenced an inspection of the service and have undertaken an initial assessment in respect of this death to determine whether criminal enforcement action should be considered and will take robust action as necessary.
Jeffrey Marshall
All Responded
2024-0450
13 Aug 2024
National Institute for Health and Care …
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.
Noted
(AI summary)
NHS England acknowledges the coroner's concerns but states that NICE is the appropriate body to provide clinical guidance. NHS England will review NICE's response and consider any resultant actions, while noting the need for individualised care in such cases. They are also gathering information on a delay in reporting a CT scan result. NICE acknowledges the lack of specific guidance on restarting anticoagulants after traumatic intracranial haemorrhage. NICE will consider the issues raised through their guidelines surveillance process and discuss a consensus statement with relevant specialist societies.
Emma, Ellette and George Pattison
All Responded
2024-0438
8 Aug 2024
Department of Health and Social Care
National Police Chiefs’ Council
Surrey Police
+2 more
Other related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.
Action Planned
(AI summary)
DHSC describes the rollout of a system by May 2023 to alert GPs when a patient with a shotgun certificate experiences a relevant medical condition, enabling them to flag it to the police. National FEO training will encourage positive engagement with the applicant and their family to ascertain their “domestic health and wellbeing”, and revised guidance may require interviews and engagement with families; the police are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners. Surrey Police has revised its practice so FEOs now ask about the use of other medical services during visits to elicit information from applicants, and notes a national initiative to rewrite questions to be more explicit. The Home Office plans to issue a refreshed version of the Statutory Guidance early in 2025, which will include additional guidance for the police to help ensure that perpetrators of domestic abuse, coercive or controlling behaviour do not have access to firearms. The GPC will update its guidance to GPs to highlight the potential information gap in firearms licensing if external prescribers don't share relevant information or patients withhold it.
Gillian Stokes
All Responded
2024-0436
8 Aug 2024
Ashford and St Peter’s Hospitals NHS Fo…
Department of Health & Social Care
Royal College of Nursing
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Noted
(AI summary)
The DHSC will explore with MHRA and NHSE raising awareness of angiosarcoma following radiation with patients and clinicians. They note that surveillance guidance for angiosarcoma may do more harm than benefit. The RCN supports the coroner's concerns regarding lack of guidance and pathways for radiation induced sarcoma, implants, and the current surveillance period. However, as a professional body, they do not comment on individual cases. Ashford and St Peters Hospitals NHS Foundation Trust is developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop Clinic that will outline guidelines for patient follow-up care, including accommodating patients requiring earlier follow-up in some circumstances. The RCR has tasked the authors of their 'Guidance on screening and symptomatic breast imaging' to consider the coroner's concerns during the current review and ensure all modalities are considered.
Wendy Hammon
All Responded
2024-0410
29 Jul 2024
Ashford and St. Peter’s Hospitals NHS F…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.
Action Planned
(AI summary)
The Trust's Serious Incident Report recommends empowering junior doctors to escalate and seek senior review. Actions to facilitate this include discussion at the Junior Doctor Forum, policy reviews, strengthening electronic patient record escalation processes, and monitoring quality improvement projects.
Jessica de Souza
All Responded
2024-0407
16 Jul 2024
BMJ Group
National Institute for Health and Clini…
Royal Pharmaceutical Society
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.
Noted
(AI summary)
The Royal Pharmaceutical Society explains that the BNF provides a general overview and may not include all information necessary for prescribing, recommending referral to a specialist for bipolar disorder. They will continue to monitor for additional information around the management of bipolar disorder for future updates. BMJ acknowledges the coroner's concerns regarding BMJ Best Practice's content on bipolar disorder treatment. They state that the tool is a reference for medical professionals and that content is regularly reviewed and updated, but the decision on treatment remains with the prescribing clinician. They highlight the importance of consulting multiple sources and checking product information sheets for medications. NICE acknowledges the coroner's concerns regarding their bipolar disorder guideline (CG185) and its consideration of the two polarities of bipolar disorder in long-term treatment. They will discuss this area with their topic experts and review any new evidence, updating recommendations if necessary.
Isabella McCreadie
All Responded
2024-0300
3 Jun 2024
Frimley Health NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with medication ordering and insufficient training for agency staff.
Action Taken
(AI summary)
Frimley NHS has implemented mandatory four-hour classroom-based Epic training for agency staff, reduced reliance on agency staff, and requires supervision of agency staff by substantive members. A review is currently being undertaken to look at demand and capacity for the whole of the therapy’s directorate including the dietetics team and a staffing proposal paper is being compiled.
Charlie Hopkins and William Robinson
Partially Responded
2024-0262
14 May 2024
Department for Transport
Driver and Vehicle and Standards Agency
Motor Ombudsman
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. Also, insufficient safety measures for young, new drivers contribute to road risks.
Noted
(AI summary)
DVSA acknowledges receipt of the coroner's report and notes that the Department for Transport will be responding on their behalf.
Zarah Ravn
All Responded
2024-0252
8 May 2024
Ashlea Medical Practice
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Mental health, physical, and medication reviews for a patient with schizophrenia and depression had not been carried out for a number of years, with a lack of monitoring and standardised process for review; no risk assessment was carried out when the patient reported a dip in her mental health.
Action Taken
(AI summary)
The practice has implemented changes to SMI annual review processes, including a new process for tasking GPs for mental health and medication reviews, reminders to use templates, and safety netting. They have also introduced a new HRT prescribing policy with questionnaires and audits, and reiterated the importance of suicide risk assessments and training.
John Bass
All Responded
2024-0251
8 May 2024
Surrey County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an ongoing risk to public safety.
Noted
(AI summary)
Surrey County Council acknowledges the coroner's concerns regarding vegetation encroachment and inspection frequency. They state that pavements are for pedestrians, not cyclists, and that the inspection regime is in line with their responsibilities and national guidance. They will, however, remind the inspection team to consider the risk to vulnerable users posed by debris.
Timothy Clayton
All Responded
2024-0206
17 Apr 2024
NHS England
St George’s Epsom and St Helier Group
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.
Action Taken
(AI summary)
NHS England highlights the meeting of the target of 5,000 additional core general and acute beds in January 2024. NHS England also notes that Epsom and St Helier University Hospitals NHS Trust has updated its Hospital Discharge and Criteria to Reside Policy and process for identifying vulnerable patients and has emphasised the importance of family involvement in decision-making. Epsom and St Helier University Hospitals NHS Trust has updated its Hospital Discharge and Criteria to Reside Policy, emphasised the importance of family involvement in decision-making, and is providing additional safeguarding training to staff. The Trust has also communicated anonymised learning and actions from the case across the organisation.
Jonathan Harris
All Responded
2024-0155
20 Mar 2024
NHS England
Suicide (from 2015)
Concerns summary (AI summary)
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
Action Planned
(AI summary)
NHS England highlights its Long Term Workforce Plan to address workforce shortages and specific investment in mental health services. It also states that the Regulation 28 Working Group discusses all reports received to share learnings and insights across the NHS.
Anne Rowland
All Responded
2024-0154
20 Mar 2024
Surrey and Sussex Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.
Action Taken
(AI summary)
Surrey & Sussex Healthcare NHS Trust outlines actions taken to improve timely surgery for fractured neck of femur patients including infrastructure improvements and process changes, resulting in improved surgery rates within 36 hours and a reduced mortality rate.
Sarah Sutherland
Partially Responded
2024-0148
15 Mar 2024
Brainwaves
Care Quality Commission
Council of Psychotherapy
+2 more
Suicide (from 2015)
Concerns summary (AI summary)
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.
Noted
(AI summary)
NHS England is working with private sector organisations to trial the use of Summary Care Records in settings where they have previously been unavailable and will continue this work throughout 2024. They also note the responsibility of providers to share information under the Health and Social Care (Safety and Quality) Act 2015. The CQC states they cannot comment on the regulation of the private psychotherapist as the practice is not registered with CQC. They welcome the action taken by Surrey and Borders Partnership NHS Foundation Trust and will continue to monitor the trust and any new information received but state this is outside the scope of their regulatory powers. The UK Council for Psychotherapy outlines its role and regulatory responsibility, noting its register of psychotherapists and Complaints and Conduct Process. They state they will not take action in relation to the coroner's first concern, but note work with the Professional Standards Authority and the NHS in discussing opportunities for collaboration in support of suicide prevention strategies.
Jake Baker
All Responded
2024-0068
8 Feb 2024
Care Quality Commission
Surrey County Council
Other related deaths
Concerns summary (AI summary)
Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult social care for care leavers. Deficiencies in risk assessment standards and non-mandatory Mental Capacity Act training persist.
Action Taken
(AI summary)
CQC has internal processes to review Regulation 28 reports, including a decision review meeting (DRM) to consider concerns and determine regulatory responses. CQC also conducted a comprehensive inspection of Glasshouse College in June 2021, resulting in an 'inadequate' rating, but a re-inspection in March 2022 found significant improvements and a 'good' rating. CQC are also working to improve links with local Learning Disability Mortality Review (LeDeR) teams and access to their data. Surrey County Council provides Pathway Plan training as part of personal advisers' induction and has had a formal training programme since at least September 2021, and updated the content in 2024 with a rolling programme of training. Mental Capacity Act training is now mandatory for all front line staff in the Adults Service.
David Mitchener
All Responded
2024-0083
19 Jan 2024
Department of Health and Social Care
Food Standards Agency
NaturPlus UK
Other related deaths
Concerns summary (AI summary)
Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side effects of excess vitamin supplements.
Noted
(AI summary)
The Food Standards Agency will raise the coroner's report at the next cross-government Food Supplements Working Group and contact relevant local authorities to ascertain whether the product is in compliance with food supplements requirements. Save on Supplements Ltd expresses condolences and states it complies with applicable law, provides information on its website and packaging for safe consumption and reviewed its operations following the inquest. It will consider implementing changes if the regulatory landscape changes. The Department of Health and Social Care discussed the issues raised in the PFD report at the Cross-Government Food Supplements Working Group meeting in April, which agreed to set up a sub-group to look at the issues raised. They have also made relevant trade associations relating to food supplements aware of the incident and will meet with them in due course.
Meghan Chrismas
All Responded
2024-0118
29 Dec 2023
Hampshire and Isle of Wight Constabulary
NHS England
Suicide (from 2015)
Concerns summary (AI summary)
Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.
Action Taken
(AI summary)
The Constabulary provided CPD training on THRIVE Risk Assessment and Re-assessment of Risk to control room staff in 2023. They adopted the THRIVE risk assessment model in October 2023 and expanded the remit of the QuAD team to audit incidents and supervisory reviews. They also launched a 'Your Call' learning publication in January 2024. NHS England highlights existing policies and guidelines, including the Summary Care Record (SCR) and professional guidelines on information sharing, to address concerns about information transfer between NHS and private healthcare providers. It also mentions a working group that reviews PFD reports to identify and address emerging trends.
Larry Spriggs
All Responded
2024-0104
22 Dec 2023
Surrey and Boarders Partnership NHS Fou…
Mental Health related deaths
Concerns summary (AI summary)
The coroner notes a lack of evidence of cultural change in patient care and treatment, as well as concerns regarding inpatient risk assessment, information passage between staff, and intermittent observation management at Farnham Road Hospital.
Action Taken
(AI summary)
The Trust has launched a new five-year strategy focused on high-quality care, an inpatient improvement plan for safety and quality improvements, and introduced the Supportive Observations Audit Tool, with a digital solution being tested for recording supportive observations. They are also leading a national work stream on workforce and training for therapeutic observations.
Barbara Woodman
All Responded
2024-0100
22 Dec 2023
NHS England
Surrey and Borders Partnership NHS Foun…
Surrey County Council
+1 more
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.
Noted
(AI summary)
Surrey Police acknowledges the PFD report but notes that no specific issues were raised in relation to their force, however they will share the findings amongst relevant teams. Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council clarify the purpose of the SCARF process and highlight existing crisis support services. A project group will be carrying out a detailed review of their cross-agency SCARF process. NHS England highlights the National Care Records Service (NCRS) and Shared Care Records, aiming for national interoperability between all Shared Care Records in England by March 2025 to improve information sharing.
John Lee
All Responded
2023-0505
6 Dec 2023
Surrey and Sussex Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.
Action Taken
(AI summary)
The Trust has already undertaken several actions, including updating the dysphagia e-learning module, introducing a rolling training programme, and planning a swallow awareness event in March 2024. It will also review the Meal time policy, relaunch Red Tray guidance, and produce communication materials promoting dysphagia awareness.
Kevin O’Hara
All Responded
2023-0472
23 Nov 2023
Surrey County Council
Other related deaths
Concerns summary (AI summary)
Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.
Action Planned
(AI summary)
Surrey County Council and Surrey Fire and Rescue Service acknowledge mistakes and outline planned improvements. These include quality assurance for Safe and Well Visits, a new risk assessment process within Adult Social Care, and updated training programs with timelines provided.
Bavaniammah Theiventhiran
Historic (No Identified Response)
2023-0444
13 Nov 2023
Surrey and Sussex Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.