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
Rainer Wickens
All Responded
2014-0234 20 May 2014
St George’s Healthcare NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.
Action Taken (AI summary) St George's Healthcare NHS Trust apologized for sub-optimal care and delays in a Serious Incident investigation. They have shared the investigation's learning outcomes, now investigate all cases of hospital-acquired thrombosis, and have completed some actions from the SI panel's report, with the rest due by 31 July 2014.
Rajesh Parkash
Historic (No Identified Response)
2014-0207 8 May 2014
Association of Ambulance Chief Executiv… London Ambulance Service
Community health care and emergency services related deaths
Concerns summary (AI summary) Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Jackson Chadd
Partially Responded
2014-0137 24 Mar 2014
Department of Health and Social Care Frimley Park Hospital Royal College of Paediatrics and Child …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Hospital updated sepsis guidelines to include tachycardia, changed practices to fast track children with PEWS scores of less than 4 to the Paediatric Assessment Unit, and now requires blood gases on all children presenting with fever or non-blanching rash; it also reiterates its philosophy of 'patient not to go home'. The RCPCH refers to existing guidance, standards and reports regarding supervision and training and notes their current review of standards to encourage higher levels of consultant supervision.
Phyllis Barnes
Historic (No Identified Response)
2014-0138 24 Mar 2014
Frimley Park Hospital NHS Trust North East Hampshire and Farnham Clinic… Royal College of Surgeons
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family 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 (AI 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 (AI 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 Medicines and Healthcare products Regul… St Peter’s and Ashford Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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 (AI 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 (AI 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
Historic (No Identified Response)
2013-0319 1 Dec 2013
Coombe Dingle Nursing Home
Care Home Health related deaths
Concerns summary (AI 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
Partially Responded
2013-0303 7 Nov 2013
ADC Surrey Harmoni
Community health care and emergency services related deaths
Concerns summary (AI 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.
Noted (AI summary) The Department of Health acknowledges the concerns about staff ratios in care homes, explains that there are no set ratios due to varying resident needs, and refers to existing regulations requiring sufficient qualified staff and the CQC's role in enforcing these regulations. It also outlines changes following the Mid Staffordshire NHS Foundation Trust Inquiry.
Peter Clive Higson
All Responded
2013-0277 24 Oct 2013
Secretary of State for Health
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Noted (AI summary) The Department of Health refers to a report from NHS Blood and Transplant which indicates that prophylactic platelet transfusion was appropriate in this case, and that the respiratory deterioration likely resulted from other causes, highlighting measures in place to minimise the risk of adverse outcomes from platelet transfusions. NHS Blood and Transplant concludes that TRALI was unlikely in this case based on SHOT imputibility criteria, recent studies and current guidelines suggest that the benefits of platelet transfusion outweigh the risk, and they undertake measures to reduce the risk of TRALI.
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 (AI summary) Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
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 (AI 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.