Newcastle

Coroner Area
Reports: 52 Earliest: Sep 2013 Latest: 17 Nov 2025

67% response rate (above 63% average).

52 results
Edward Cockburn
Response Pending
2021-0415
City Hospitals Sunderland NHS Foundatio… The Jackloc Company Limited Department for Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Product related deaths
Concerns summary (AI summary) Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or audit the efficacy of delivered training.
Disputed (AI summary) Sunderland Royal Hospital has completed remedial estates work to fit additional window restrictors and swipe card access in key areas, and updated its Enhanced Care/Observation Standard Operating Procedure. They are now developing e-learning packages for SafeCare and EICO, to be uploaded to the ESR system for recording and auditing staff training. Jackloc Company Ltd disputes the need to alter fitting instructions or communicate changes to Trusts, arguing their instructions remain fit for purpose. They will, however, amend their data sheet to align it with fitting instructions, allowing for attachment to either the window frame or sill.
Neil Stewart
Historic (No Identified Response)
2021-0400 25 Nov 2021
Bounce Til I Die
Other related deaths Product related deaths
Concerns summary (AI summary) There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.
Marion Clode
All Responded
2021-0228
JM Nixon Ltd, Swinhoe Farm Belford Nort…
Other related deaths
Concerns summary (AI summary) The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn the public of risks. Insecure holding pens and an unutilised gate design contributed to the danger.
Action Planned (AI summary) J M Nixon Son has revisited and made changes to its cattle movement plan, including no longer using a second holding area, implementing a new quadbike system for checking the track for public, and placing 'Warning Cattle being Moved' signs. Defra is undertaking reforms to the rights of way system, including a 'Right to Apply' provision for landowners to divert or extinguish paths and guidance to encourage removal of paths from private areas. The response also details HSE's existing investigation procedures and analysis of cattle incidents.
Benjamin Clark
All Responded
2021-0236 8 Jul 2021
Northumbria Health Care Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient daily reassessment of falls risk.
Noted (AI summary) The Trust states that changes were implemented following a Serious Incident investigation. They describe using AFLOAT to assist with setting observation levels, but the final decision is based on the nurse's professional judgement.
Ewan Brown
Historic (No Identified Response)
2020-0235 10 Nov 2020
Northumbria Police, Newcastle City Coun…
Community health care and emergency services related deaths Mental Health related deaths Other related deaths Police related deaths
Concerns summary (AI summary) A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.
Maureen Wharton
Historic (No Identified Response)
2019-0420 6 Dec 2019
Cumbria, Northumberland, Tyne & Wear NH… North East Ambulance Service NHS Trust Northumbria Police Service
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.
Philip Hayes
Historic (No Identified Response)
2019-0363 30 Oct 2019
North East Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained health advisors who inadequately considered reported symptoms of a medical emergency.
Pauline Howell
All Responded
2019-0498 9 Aug 2019
Newcastle Upon Tyne City Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The coroner raises concerns about the John Dobson Street crossing, citing foreseeable pedestrian error, its proximity to a busy junction, challenging conditions for bus drivers, and a design that allows no margin for error, noting previous fatal incidents.
Action Planned (AI summary) Newcastle City Council commissioned two independent Road Safety Audits and will install text on the kerb edge at pedestrian crossing points stating 'Look both ways'. Other minor scheme improvements include amending tactile paving, revising the phasing of lights, and replacing damage on a splinter island.
Maia Strachan
Partially Responded
2019-0174 28 May 2019
North Tyneside Hospital Northumbria Health Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.
Action Taken (AI summary) The Trust has reviewed current training around documentation standards and it is provided as part of the PROMPT annual training. An ongoing monthly audit of notes will occur, and a quarterly report will be generated. Additional training will be provided to midwives around bereavement and the medical examiner role is being reviewed.
Archie Grieves
Historic (No Identified Response)
2019-0190 12 Apr 2019
Gateshead Health NHS Trust
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text.
Stephen Pettitt
Partially Responded
2019-0037 25 Jan 2019
Newcastle upon Tyne NHS Foundation Heal… Royal College of Surgeons of England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.
Action Planned (AI summary) The Royal College of Surgeons will highlight relevant guidance on training and consent when introducing new surgical techniques and technologies to its members. They are planning to highlight all relevant guidance to members and fellows through newsletters, communications with NHS hospital trusts and independent hospitals, and will continue to monitor advances in technology and innovation.
Edward Farmer
All Responded
2018-0390 12 Dec 2018
Department for Education
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance of timely medical intervention.
Action Planned (AI summary) The Department for Education highlights the publication of comprehensive guidance by Universities UK and Newcastle University, "Initiations at UK Universities", which addresses the risks of initiations and excessive alcohol consumption among students. The guidance includes recommendations on staff training, disciplinary processes, reporting systems, and awareness raising. Following a roundtable event, Universities UK and Newcastle University published guidance to raise awareness of the dangers of initiations and excessive alcohol consumption among students. Public Health England is engaged in several actions targeted at young people about the dangers of excessive alcohol consumption. Newcastle University and the Students' Union have undertaken several actions, including enhanced training for student leaders, revised guidance, increased communications and awareness campaigns, and closer collaboration between university departments and the Students’ Union, with plans for continued monitoring and embedding of these practices. The Department of Health and Social Care will work with government colleagues and other health sector bodies to determine the best course of action regarding the risks of alcohol consumption. The Secretary of State for Education has deferred a response until the department has worked with colleagues in the health and education sectors on designing measures to raise awareness of the risks of alcohol consumption and initiation events. NUS plans to convene a meeting with the Home Office, Department for Education, Public Health England, Universities UK, and the Office for Students before the end of March 2019 to explore collaborative work on responsible alcohol consumption, potentially scaling up the Alcohol Impact program.
Ellie Knowles
Historic (No Identified Response)
2018-0202 18 Jul 2018
Hoults Limited Shindig Events Limited
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.
Graeme Flatman
All Responded
2017-0393 10 Nov 2017
Cumbria County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph speed limit on this challenging single carriageway road.
Action Planned (AI summary) Cumbria County Council will review signage at the collision location with the police and install any measures before the end of March. They will also look at the appropriateness of the 60 mph speed limit, but any changes will require a consultation and legal process taking at least 6 months.
Liam Hall
Historic (No Identified Response)
2017-0242 27 Jul 2017
Sunderland City Council
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker Harbour.
Sheila Hynes
Historic (No Identified Response)
2017-0448 3 Jul 2017
Newcastle Upon Tyne NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Helen Patton
All Responded
2016-0152 20 Apr 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.
Noted (AI summary) The Department of Health acknowledges concerns regarding mini tracheostomy procedures, and includes a joint response from the Faculty of Intensive Care Medicine (FICM) and the Royal College of Anaesthetists (RCOA). They confirm that routine use of ultrasound is not mandated and references various guidelines related to tracheostomy procedures. The Faculty of Intensive Care Medicine and Royal College of Anaesthetists reviewed information about a death following a minitracheostomy, but state the provided data is inadequate to answer questions definitively and note that routine ultrasound is not mandated prior to minitracheostomy.
Steven Nicholson
All Responded
2016-0135 30 Mar 2016
Durham County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.
Action Planned (AI summary) The council is implementing a scheme to improve highway drainage by replacing side gullies with more effective open gullies, expecting completion by the end of July 2016. They have arranged for temporary flood warning signs to be deployed until the works are complete.
Tamara Mills
Historic (No Identified Response)
2015-0416 29 Oct 2015
Farnham Medical Centre Health Education England National Institute for Health and Care … +6 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.
Patrick Carrick
All Responded
2015-0374 9 Oct 2015
North Tyneside General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.
Action Taken (AI summary) Northumbria Health Care NHS Trust has implemented monthly audits by Matrons to check adherence to management plans, provided NEWS training, and is procuring an electronic track and trigger system for NEWS. They have also reported NEWS compliance monthly and made changes to NEWS to incorporate sepsis management.
Paul Coxon
All Responded
2015-0286 20 Jul 2015
Gateshead Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road where driver visibility is limited create significant hazard.
Action Taken (AI summary) An additional sign will be erected at the top of the steps indicating a pedestrian route. Infill panels have been installed on the guardrail to minimise the hazard relating to the presence of pedestrians on the carriageway.
Olive Nugent
Historic (No Identified Response)
2015-0134 31 Mar 2015
South Tyneside Council
Other related deaths
Concerns summary (AI summary) Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Edwin Thompson
Historic (No Identified Response)
2014-0542 22 Dec 2014
Quality Care Commission South Tyneside Council
Community health care and emergency services related deaths
Concerns summary (AI summary) A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Anthony Lapping
All Responded
2014-0214 8 May 2014
Indesit Company
Product related deaths
Concerns summary (AI summary) Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Noted (AI summary) The company outlines the safety standards in place at the time of manufacture and improvements made since. It describes assessments underway to reduce flammability further but describes constraints on introducing an aluminized cardboard covering.
Vincent Gibson
Historic (No Identified Response)
2014-0148 1 Apr 2014
Independent Police Complaints Commission Northumbria Police
Police related deaths
Concerns summary (AI summary) Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.