Recurring concern

Failure to reliably report deaths to coroners

First to latest report 1 Jul 2014 — 25 Nov 2025

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
3

What this concern includes

Includes failures in the process for recognising, deciding, documenting and making required or appropriate reports of deaths to coroners, including inappropriate advice about whether to call the Coroner and late, omitted or potentially improper reporting of neonatal or child deaths.

What is not included
  • Excludes post-mortem, autopsy, inquest and death-investigation deficiencies after a death has been appropriately reported to the Coroner.
  • Excludes failures in determining or recording the cause of death where the coroner-reporting decision itself is not deficient.
  • Excludes generic death notification or verification-record errors that do not affect whether a death is appropriately reported to the Coroner.
  • Excludes police, organ-donation or other judicial decisions unless they directly concern reporting a death to the Coroner.

Reports and published responses 9 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cambridgeshire and Peterborough

    AI-generated summary

    Benedict BLYTHE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to raise possible anaphylaxis deaths with the senior coroner at the earliest opportunity

    Wider context from the report

    “1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”

    Source location

    Benedict BLYTHE · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Suspected anaphylaxis should be raised with the Coroner’s officer by the referring medical practitioner or police before the pathologist is contacted.

    Verbatim wording from the response

    “If a death due to anaphylaxis is suspected, this should be raised by the initial referring medical practitioner to the Coroner’s officer or by the police. The case to which the Coroner’s queries are raised should have anaphylaxis or allergic reaction in the potential cause of death or in the deceased’ situational history before the pathologist was contacted. It is usual practice for the autopsy pathologist to communicate a suspected cause of death to the Coroner after the initial examination pending the results of further investigations, however, it is not always possible for a pathologist to be definite at that stage.”

    Source location

    Response from Royal College of Pathologists
    Page 2 · response
    Published 2 December 2025

    Open published response

  2. Inner West London

    AI-generated summary

    Elton Deutekom · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to appropriately refer neonatal deaths to the coroner

    Wider context from the report

    “1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all, and this raises the possibility that lessons may not be learned from the investigation of these deaths that may save the lives of others. ”

    Source location

    Elton Deutekom · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of neonatologists to appropriately report deaths to the coroner

    Wider context from the report

    “9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner. ”

    Source location

    Elton Deutekom · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reiterate to neonatal and Trust leadership staff that concerns about a death should prompt referral to the Coroner.

    Verbatim wording from the response

    “The Neonatal team liaise with the Medical Examiners and maternity teams in the event of a neonatal death and referrals are made appropriately and according to existing criteria.”

    Source location

    Response from Chelsea and Westminster NHS Foundation Trust
    Page 3 · response
    Published 3 December 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.

    Verbatim wording from the response

    “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 3 December 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.

    Verbatim wording from the response

    “My response to your Report focuses on the areas of concern raised by the Coroner that sit within NHS England’s national policy and programme remit. Your Report raises a number of concerns specific to Chelsea and Westminster Hospital and it is appropriate that Chelsea and Westminster NHS Foundation Trust, who I note you have also sent your Report to, respond to you on these matters. I wish to assure you that the National Medical Examiner, who you have also addressed your Report to, has reviewed your Report and has input into my response.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 3 December 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.

    Verbatim wording from the response

    “The Trust is confident that it meets its obligations in respect of referring neonatal deaths to the Coroner.”

    Source location

    Response from Chelsea and Westminster NHS Foundation Trust
    Page 3 · response
    Published 3 December 2024

    Open published response

  3. East London

    AI-generated summary

    Chloe Every · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in reporting deaths to a Coroner

    Wider context from the report

    “7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023, by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy. ”

    Source location

    Chloe Every · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review all deaths through the Medical Examiner Office, including cause-of-death certification, bereaved-family concerns and referrals for further review.

    Verbatim wording from the response

    “Since September 2024 all deaths have been reviewed by the Medical Examiner Office. The role of these offices is to examine deaths to:”

    Source location

    Response from Barking, Havering and Redbridge NHS Foundation Trust
    Page 6 · response
    Published 31 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.

    Verbatim wording from the response

    “NHSE have informed us that BHRUT is preparing a response to address your concerns in full. This is entirely appropriate due to the nature of the concerns raised and as a direct recipient of this report. I look forward to their response with interest and do not wish to duplicate it. However, I will highlight some points from the information shared with us, of the actions taken to improve matters in relation to the care of patients with learning disabilities since Chloe’s death in 2019:”

    Source location

    Response from DHSC
    Page 1 · response
    Published 31 October 2024

    Open published response

  4. Avon

    AI-generated summary

    Celia Lindsey MARSH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in raising suspected anaphylaxis deaths with the Senior Coroner

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establishing the systems identified by the Coroner falls outside UKHSA’s remit.

    Verbatim wording from the response

    “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.”

    Source location

    Response UK Health Security Agency
    Page 1 · response
    Published 25 November 2022

    Open published response

  5. Manchester North

    AI-generated summary

    Nichola Jane Lomax · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Under-reporting of eating disorder deaths to the coroner

    Wider context from the report

    “7) Lack of Recognition of the need to Investigate For National Medical Examiner It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder. ”

    Source location

    Nichola Jane Lomax · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.

    Verbatim wording from the response

    “The National Medical Examiner is also concerned about deaths of people with eating disorders. In late 2021, the National Medical Examiner’s team proposed a round table discussion with subject matter experts and stakeholders, including representatives from the Chief Coroner’s office, with a view to publishing guidance for medical examiners through the National Medical Examiner’s series of Good Practice papers. The round table discussion to inform this paper is due to take place in February 2022, with publication expected later in 2022.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 16 · response
    Published 31 December 2021

    Open published response

  6. North East Kent

    AI-generated summary

    HARRY RICHFORD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to notify the Coroner of a child death

    Wider context from the report

    “Concern 17 The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this. ”

    Source location

    HARRY RICHFORD · Prevention of Future Deaths report
    Page 19 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

    Verbatim wording from the response

    “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 October 2022

    Open published response

  7. Manchester South

    AI-generated summary

    Elsie Clarke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide appropriate advice on calling the Coroner or police

    Wider context from the report

    “(10) The doctor advised the Home that in the present case there was no need to call the Coroner/police ”

    Source location

    Elsie Clarke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Gap in Out of Hours doctors’ training on reporting deaths to the Coroner

    Wider context from the report

    “(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”

    Source location

    Elsie Clarke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Isle of Wight

    AI-generated summary

    Barbara Monica May Cooke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts

    Wider context from the report

    “5. I am further concerned that there is currently no system in place at St Mary’s Hospital to automatically contact the Coroner to refer the matter for investigation when a person who is the subject of a Safeguarding alert dies whilst an inpatient in the Hospital. ”

    Source location

    Barbara Monica May Cooke · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  9. Brighton and Hove

    AI-generated summary

    John Henry ADAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Henry Adams died following multiple complications of an appropriate cardiac intervention after being recruited to a cardiac trial just before the procedure. Concerns included whether there was sufficient time for informed consent, the suitability and preparedness of the trial operator, and the recording and communication of the trial’s possible relevance to the cardiac tamponade and subsequent death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to notify the Coroner of a trial patient's death and trial involvement

    Wider context from the report

    “(9) Finally; surely the death of a patient while on a Trial is a matter of major concern to the Trial itself and yet no-one contacted the Coroner, either the original Coroner in South London or me, Coroner for Brighton and Hove when I took over jurisdiction pursuant to Section 2 of the Coroner’s and Justice Act, to let us know that this man had been on a Trial. If I had known that, and in particular if I had been able to tell ████████ of that fact, she would have been able to ascertain precisely where the bleeding/haemorrhage originated and there would have been good clear helpful information for those managing the Trial and of course future patients who might have benefited from it. ”

    Source location

    John Henry ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026