Surrey

Coroner Area
Reports: 187 Earliest: Aug 2013 Latest: 19 Dec 2025

78% response rate (above 62% average).

Response Status
Responded 145 No Response 1 Historic 38
AI Classification
Action Taken 48%
Action Planned 29%
Noted 14%
Disputed 10%
Based on 80 classified responses
Top Categories
Hospital Death (Clinical Procedure… (67) Suicide (from 2015) (31) Other related deaths (23) Community health care and emergenc… (18) Care Home Health related deaths (18)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: +106 reports · +18pp response rate
vs national average: +104 reports · +16pp response rate
187 results
Jackson Chadd
Partially Responded
2014-0137 24 Mar 2014
Department of Health and Social Care Royal College of Paediatrics and Child … Frimley Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Keith Martin
Historic (No Identified Response)
2014-0055 5 Feb 2014
St Peter’s and Ashford Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.
Amy Friar
Historic (No Identified Response)
2014-0051 3 Feb 2014
Ministry of Justice
State Custody related deaths
Concerns summary The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.
William Kent
Historic (No Identified Response)
2014-0056 31 Jan 2014
Guest Medical St Peter’s and Ashford Hospitals Medicines and Healthcare products Regul…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.
Lillian Robinson
Historic (No Identified Response)
2014-0041 26 Jan 2014
Surrey County Council
Care Home Health related deaths
Concerns summary The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.
Sarah Shepherd
Historic (No Identified Response)
2013-0359 16 Dec 2013
Surrey and Borders Partnership NHS Foun…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.
John William Tugwell
Unknown
2013-0319 1 Dec 2013
Care Home Health related deaths
Concerns summary The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Stanley Dobson
All Responded
2013-0303 7 Nov 2013
Community health care and emergency services related deaths
Concerns summary Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
Action taken summary The Department of Health explicitly rejects the suggestion of establishing national staffing ratios for care homes, stating it is not practical and there is no intention to add them to …
Peter Clive Higson
All Responded
2013-0277 24 Oct 2013
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Action taken summary The Department of Health, following advice from NHS Blood and Transplant, concluded that prophylactic platelet transfusion was appropriate for the deceased and that the respiratory deterioration was l
Frederick Davidson
Historic (No Identified Response)
2013-0258 14 Oct 2013
Department of Health and Social Care Epsom and St Helier University Hospital…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.
Vera Lillian Steel
Historic (No Identified Response)
2013-0185 13 Aug 2013
Care Quality Commission South East England Fire and Rescue Serv…
Care Home Health related deaths
Concerns summary A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.
Volodymyr Korol
Response Pending
2022-0170
Whitepost healthcare Group
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. Similar deficient practices may pose a risk at their other operational nursing home.