Teesside and Hartlepool
Coroner Area
Reports: 25
Earliest: Nov 2013
Latest: 5 Nov 2025
88% response rate (above 62% average).
Vivian Nolan
All Responded
2025-0560
5 Nov 2025
President of the British Society of Gas…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
Action taken summary
The British Society of Gastroenterology clarifies that current UK guidance emphasizes individualised patient consent, balancing risks and benefits for colonoscopy, including for those over 80. They di
Dean Bradley
All Responded
2025-0248
28 May 2025
Hartlepool Council
Tees, Esk and Wear Valleys NHS Foundati…
Stockton Council
+4 more
Police related deaths
Suicide (from 2015)
Concerns summary
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Diana Fairweather-Purkis
All Responded
2025-0091
17 Feb 2025
NHS NORTH EAST AND NORTH CUMBRIA INTEGR…
NHS ENGLAND
DEPARTMENT OF HEALTH
Emergency services related deaths (2019 onwards)
Concerns summary
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
Gary James
All Responded
2025-0083
12 Feb 2025
Ward Bros (Malton) Ltd
Accident at Work and Health and Safety related deaths
Concerns summary
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety concerns and supervision.
John Cogdon
All Responded
2024-0631
15 Nov 2024
South Tees Hospitals NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.
Margaret Huntley
All Responded CC
2024-0452
13 Aug 2024
Association of Ambulance Chief Executiv…
North East Ambulance Service NHS Founda…
NHS England
+1 more
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.
Michael Dalkin
All Responded
2024-0243
2 May 2024
REDACTED
Alcohol, drug and medication related deaths
Concerns summary
The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.
Victor Costello
All Responded
2024-0141
14 Mar 2024
Stockton Care Limited
Care Home Health related deaths
Concerns summary
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Donna Smith
All Responded
2024-0037
22 Jan 2024
North East Ambulance Service Foundation…
Department of Health & Social Care
Emergency services related deaths (2019 onwards)
Concerns summary
The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.
Kate O’Donnell
All Responded
2024-0038
22 Jan 2024
James Cook University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.
John Taylor
All Responded
2023-0525
15 Dec 2023
North East Ambulance Service NHS Founda…
Emergency services related deaths (2019 onwards)
Concerns summary
Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.
Lincoln Brady
All Responded
2016-0118
23 Mar 2016
South Tees Hospitals NHS Foundation Tru…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Mandeep Singh
All Responded
2016-0116
23 Mar 2016
North East Ambulance Service NHS Founda…
Community health care and emergency services related deaths
Concerns summary
Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Margaret Metcalfe
All Responded
2016-0107
14 Mar 2016
Rosedale Care Home
Care Home Health related deaths
Concerns summary
Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.
Keri Holdsworth
All Responded
2015-0060
18 Feb 2015
Highways Agency
Hartlepool Borough Council
Road (Highways Safety) related deaths
Concerns summary
This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for vehicles making right turns to or from the northbound A19.
Kirk Williams
All Responded
2014-0499
14 Nov 2014
IPCC
Police related deaths
Concerns summary
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.