Surrey

Coroner Area
Reports: 189 Earliest: Aug 2013 Latest: 10 Apr 2026

77% response rate (above 63% average).

Response Status
Responded 146 No Response 1 Historic 39 Pending 2
AI Classification
Action Taken 41%
Action Planned 36%
Noted 22%
Disputed 2%
Based on 262 classified responses
Top Categories
Hospital Death (Clinical Procedure… (68) Suicide (from 2015) (31) Other related deaths (23) Mental Health related deaths (18) Care Home Health related deaths (18)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: +107 reports · +17pp response rate
vs national average: +105 reports · +14pp response rate
189 results
REDACTED
Partially Responded
9 Nov 2020
Domestic Abuse Management Board Surrey … Surrey County Council
Suicide (from 2015)
Concerns summary (AI summary) The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.
1 response from Response to Surrey coroner area Prevention of future deaths report dated
Linda Doherty
All Responded
2020-0224 5 Nov 2020
Surrey and Sussex Healthcare NHS Trust
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.
Action Planned (AI summary) The Trust's response includes an action plan with actions such as the Nutrition Steering group overseeing an audit to assess the impact of MaST nutrition training, appointing a professional lead and a lead dietician, and agreeing funding for an additional nutritional nurse specialist, all with deadlines for completion.
Mitica Ladunca
All Responded
2020-0125 9 Jun 2020
Surrey County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for those traversing both carriageways.
Action Planned (AI summary) The Area Highway Manager will install advance signage at the location of the incident, scheduled for 29/30 September, coordinated with the County’s high speed Traffic Management programme.
Theo Young
Partially Responded
2020-0094 20 Apr 2020
Department of Health and Social Care East Surrey Hospital HSIB +1 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Disputed (AI summary) HSIB has made changes to its investigation methodology and processes to enable them to share early learning with Trusts following the investigation into Theo’s death. The Healthcare Safety Investigation Branch (HSIB) disputes the coroner's concerns, stating they provided opportunities for safety information to be shared and acted upon, and that inaccuracies were not due to their error. HSIB maintains its investigation was conducted in line with statutory directions. Surrey & Sussex Healthcare NHS Trust increased midwifery staffing, instituted daily staff allocation reviews, improved CTG monitoring and interpretation via training and audits, and recruited a Senior Lead Midwife. These actions led to an 'Outstanding' CQC rating in January 2019.
Andrew Wing
Partially Responded
2020-0089 3 Apr 2020
College and Society of Radiographers General Medical Council Royal College Emergency Medicine
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for accurate diagnosis.
Noted (AI summary) The General Medical Council acknowledges the concerns and has forwarded the report to their Employer Liaison Adviser to discuss with the Trust. If the Trust identify any individual clinicians whose fitness to practise may be impaired, they will refer to the GMC. The Society of Radiographers acknowledges the coroner's concerns and highlights the importance of referrers providing sufficient clinical information under the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 17). They are working with other bodies to promote understanding of IR(ME)R 17 and new guidance is in preparation.
Jordan Aira
Partially Responded
2020-0082 30 Mar 2020
Department for Education Network Rail South Western Railway
Child Death (from 2015) Railway related deaths
Concerns summary (AI summary) Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live rail dangers, and lack of related education in the national curriculum create significant railway safety risks.
Noted (AI summary) SWR outlines existing signage at Ashford station and describes its participation in national campaigns and initiatives to raise awareness of railway safety and reduce trespassing. They do not consider further action is required, but will continue to engage with the wider rail group. Network Rail describes existing measures to prevent access to the railway tracks, including physical barriers and signage, as well as ongoing educational programs and safety campaigns. They have reduced overall trespass incidents by 24% and youth trespass by 32% in two years.
Karen Bingham
All Responded
2020-0081 30 Mar 2020
South East Ambulance Service Surrey Constabulary
Emergency services related deaths (2019 onwards) Mental Health related deaths Other related deaths
Concerns summary (AI summary) Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.
Action Planned (AI summary) SECAmb, in collaboration with Surrey, Sussex and Kent police forces, will review its Surge Management Plan and explore opportunities for closer collaborative working, aiming for implementation by the end of the year. They will also work to ensure partner agencies disseminate information internally. Surrey Police updated the "Mental Health Guide" on officers' Mobile Data Terminals, delivered training from SECamb to Contact Centre and Force Control Room staff in 2018, and hold quarterly meetings with SECamb's Emergency Operations Centre. A new Decision Support Flowchart has also been agreed for implementation in October 2020.
Iris Skinner
All Responded
2019-0427 17 Dec 2019
Barchester Healthcare
Care Home Health related deaths
Concerns summary (AI summary) Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.
Action Taken (AI summary) Windmill Manor has created a new Agency Folder with key policies. Barchester is rolling out a modified induction checklist, pocket guide and poster across all homes by the end of February 2020, and compliance will be checked via the Quality Governance Framework.
JJ Wilson
All Responded
2019-0243 17 Jul 2019
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of injury or death from fire in the event of a crash, despite their availability.
Disputed (AI summary) The Health and Safety Executive believes existing UK law requiring assessment of foreseeable risk is sufficient regarding the need for fire-retardant overalls and that no further action is required. They state that FIA regulations are outside of HSE's comment.
Lucy Lee
Historic (No Identified Response)
2019-0509 15 Jul 2019
British Medical Association Department of Health and Social Care Surrey Police +2 more
Other related deaths
Concerns summary (AI summary) A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.
Christine Lee
Historic (No Identified Response)
2019-0509-wp27242 15 Jul 2019
British Medical Association Department of Health and Social Care Surrey Police +2 more
Other related deaths
Concerns summary (AI summary) The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with officers lacking skills to evaluate complex health conditions.
Charles Knapp
Historic (No Identified Response)
2019-0212 26 Jun 2019
Angel Solutions (UK) Limited
Community health care and emergency services related deaths
Concerns summary (AI summary) Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.
Geoff Gray
Partially Responded
2019-0216 20 Jun 2019
Chief Coroner of England and Wales President of the Royal College of Patho…
Other related deaths
Concerns summary (AI summary) There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, potentially leading to undetected homicides.
Action Taken (AI summary) The Chief Coroner issued guidance to coroners regarding post-mortem examinations in cases of potential self-inflicted injury, emphasizing thoroughness and consideration of forensic pathology. This guidance supersedes previous Home Office guidance.
Alice Dixon
Historic (No Identified Response)
2019-0132 5 Apr 2019
Ashford and St Peter’s Hospitals NHS Tr…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.
Terrence Smith
Historic (No Identified Response)
2019-0095 21 Feb 2019
College of Policing Joint Royal Colleges Ambulance Liaison … Mitie +4 more
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting emergency response.
Natasha Chin
Partially Responded
2019-0011 10 Jan 2019
Chief Inspector of Prisons Care Quality Commission MOJ +1 more
State Custody related deaths
Concerns summary (AI summary) Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Noted (AI summary) HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison service to take any specific action.
Kirsty Walker
All Responded
2018-0396 19 Dec 2018
Department of Health and Social Care NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.
Action Planned (AI summary) NHS England is undertaking demand and capacity reviews for adult secure services, aiming to optimise capacity and throughput, with results expected in 2019/20. They are also revising prison transfer and remission guidance, and expect this to make the transfer/remission process more efficient. NHS England is undertaking service reviews across all adult high, medium and low secure services and reviewing the current prison transfer and remission guidance. A new service specification for an integrated mental health service for prisons in England is being implemented.
Emmett Gillah
Historic (No Identified Response)
2018-0357 16 Nov 2018
Kent and Medway NHS Social Care Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.
Rita Taylor
Partially Responded
2018-0225 12 Jun 2018
Care Quality Commission Epsom General Hospital Royal College of Physicians
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient care plan.
Action Taken (AI summary) The Trust has revised its procedures and processes to ensure that all patients with hyponatraemia will have a clear treatment plan to correct their sodium in line with recognised guidance. The case was also presented at the Epsom Hospital Grand Round meeting and circulated to all consultants within the Trust.
Henry Heselton
All Responded
2018-0152 18 May 2018
Southern Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.
Action Taken (AI summary) Southern Health NHS Foundation Trust revised the Risk Summary Section in its electronic patient record in January 2017, requiring all staff to input risk information according to national guidance. The Acute Mental Health Team and Community Mental Health Team Standard Operating Procedures have been reviewed, and team managers have been instructed to ensure that staff communicate with GPs after triaging referrals and to regularly monitor that it is occurring.
Doris Ridgwell
Partially Responded
2018-0151 15 May 2018
Care Quality Commission Epsom & St Helier University Hospital N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to fatal complications.
Action Taken (AI summary) The Trust has revised its Standard Operating Procedure for telephoning coagulation results to ensure urgent abnormal blood results are communicated effectively, including escalation to the Site Manager if necessary. It has also re-issued guidance to clinical staff clarifying their responsibility to communicate clinically urgent abnormal blood results to patients and take appropriate action, even after discharge.
Stephen Tidey
All Responded
2018-0140 8 May 2018
Surrey & Borders Partnership NHS Trust Surrey County Council Surrey Police
Police related deaths State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.
Noted (AI summary) The Trust has already implemented a standardised log for Single Combined Assessment of Risk Forms (SCARF) across Community Mental Health Recovery Service (CMHRS) teams. They have also devised a new checking system between the MASH and the CMHRS teams and set up an automated email reply from the Mental Health/Drug & Alcohol inbox within the MASH. Surrey Police explains how Multi Agency Safeguarding Hub (MASH) reports are processed upon receipt and graded for risk. They state that they do not monitor partner agency responses and suggest forwarding one question to SABP and Adult Social Care.
Margaret Silver
All Responded
2018-0002 3 Jan 2018
Ashford and St Peter’s Hospital NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.
Action Taken (AI summary) The trust is amending the discharge letter template to improve clarity regarding medications. They also intend to introduce electronic prescribing in 2019, and are implementing a 'Red Bag' process to improve communication between providers.
Ronald Farrington
Partially Responded
2017-0494 22 Dec 2017
Surrey First Community Health Care Care Quality Commission Saffronland Homes limited +1 more
Care Home Health related deaths
Concerns summary (AI summary) The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Action Taken (AI summary) Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries in progress for over 12 months. The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited by staff and SMT.
Ernest Smith
All Responded
2017-0459 14 Dec 2017
Surrey and Borders Partnership NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.
Action Planned (AI summary) The Adult Mental Health Division has created an action plan to address the coroner's concerns, which will be monitored at monthly Quality Assurance Group meetings and shared with other service divisions.