top of page

Inquests (PFDs)

Date
Reference
Deceased
Coroner Area
Sent to
Investigation
Circumstances
Sent to
Categories
Also sent to
2 June 2021
2021-0262
Geoffrey Hill
Black Country
Hospital Death (Clinical Procedures and medical management) related deaths
National Institute for Health and Care Excellence
1 October 2020
2020-0194
Daphne McKenna
West Yorkshire (Western)
Other related deaths
Calderdale Council
9 October 2020
2020-0203
Brian Griffiths
Swansea and Neath Port Talbot
Road (Highways safety) related deaths; Wales prevention of future death reports
South Wales Police
12 October 2020
2020-0204
Piotr Kierzkowski
Suffolk
Suicide; Mental health related deaths;
Department of Health and Social Care
27 October 2020
2020-0222
Martin Barrett
North East Kent
Suicide; Mental health related deaths
The Priory Group
16 August 2021
2021-0272
Kumbulani Mtombeni
West London
Alcohol, drug and medication related deaths |�Care Home Health related deaths |�Suicide (from 2015)
Grassy Meadow Care Centre
22 October 2020
2020-0213
Karen Jane Winn
Suffolk
Community healthcare related deaths; Hospital death (Clinical procedures and medical management) related deaths
West Suffolk Hospital
11 November 2020
2020-0233
Margaret Sales
Norfolk
Hospital Death (Clinical Procedures and medical management) related deaths
Queen Elizabeth Hospital
5 November 2020
2020-0224
Linda Doherty
Surrey
Hospital Death (Clinical Procedures and medical management) related deaths | Community healthcare
Surrey and Sussex Healthcare NHS Trust
7 December 2020
2020-0274
Deceased names: Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Cornwall and Isles of Scilly
Product related deaths
Department of Business, Energy and Industrial Strategy | Office for Product Safety and Standards
31 March 2020
2020-0083
Michael Bostock
Derby and Derbyshire
Other related deaths
The British Hang Gliding and Paragliding Association Ltd
23 March 2020
2020-0074
Lewis Francis
Exeter and Greater Devon
Mental Health related deaths; Suicide (from 2015); State Custody related deaths
Devon Partnership NHS Trust; Devon and Cornwall Police; Avon and Somerset Police; Wiltshire Police; Gloucestershire Police; Prison and Probation service
1 November 2019
2019-0458
Joshua Hoole
Birmingham and Solihull
Service Personnel related deaths
MOD
3 December 2019
2019-0409
Luke Jones
North Wales (East and Central)
Alcohol, drug and medication related deaths; State Custody related deaths; Wales prevention of future deaths reports (2019 onwards)
HMP Berwyn; MOJ
29 November 2019
2019-0408
Leah Cambridge
West Yorkshire (East)
Hospital Death (Clinical Procedures and medical management) related deaths
GMC; Department of Health and Social Care
5 December 2019
2019-0417
Gemma Macdonald
Suffolk
Alcohol, drug and medication related deaths; Mental Health related deaths
Medicines and Healthcare products Regulatory Agency | 1st For Health International; StockXS Limited
5 December 2019
2019-0418
Darren Wilson
Lincolnshire
Road (Highways Safety) related deaths
Lincolnshire County Council
20 December 2019
2019-0446
Keith Hill
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Barts Health
10 February 2021
2021-0032
Jason O�Rourke
Inner South London
State Custody related deaths | Mental Health related deaths |�Suicide (from 2015)
HMP Belmarsh and HMPS
17 December 2019
2019-0427
Iris Skinner
Surrey
Care Home Health related deaths
Barchester Healthcare
13 December 2019
2019-0428
Steven Marsland
Manchester (South)
Community health care services related deaths; Hospital Death (Clinical Procedures and medical management) related deaths; Suicide (from 2015)
Department of Health and Social Care | Tameside and Glossop Clinical Commissioning Group | Pennine Care NHS Trust
17 December 2019
2019-0436
Constance Robinson
Manchester (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Greater Manchester Stroke Operational Delivery Network; Salford Royal Hospital
31 December 2019
2019-0456
Jacob Bates
Derby & Derbyshire
Community health care related deaths | Mental Health related deaths | Suicide (from 2015)
Department for Education
12 February 2021
2021-0042
Lucy Colgate
Surrey
Other related deaths
President of Association of British Neurologists, Chief Executive of Epilepsy Action and President of the Royal College of Paediatrics and Child Health
9 January 2020
2020-0003
Colin North
Birmingham and Solihull
Other related deaths
Incarace; ORCi
18 December 2019
2019-0437
Katherine Stamp
West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths
NHS England
25 September 2019
2019-0447
William Moody
Hampshire
Emergency services related deaths (2019 onwards); Suicide (from 2015); Mental Health related deaths
BT; Hampshire Constabulary; South Hampshire Ambulance Service
22 November 2019
2019-0399
Jonathan Adebanjo
London Inner (North)
Other related deaths
London Borough of Tower Hamlets
21 February 2021
2021-0052
Luke Jackson
Mid Kent and Medway
Hospital Death (Clinical Procedures and medical management) related deaths | Child Death (from 2015)
Dept. of Health, Royal College of GPs and Medway NHS Foundation Trust
2 February 2021
2021-0022
Cyril Cheetham
South Manchester
Community health care |�Other related deaths
Department of Health and Social Care and NHS Stockport Clinical Commissioning Group
15 January 2021
2021-0012
Kevin Lovatt
Staffordshire South
Alcohol, drug and medication related deaths |�Other related deaths
Director General of Prisons and NHS England Health and Justice Regional Team Chair
9 December 2019
2019-0485
John Wells
West Sussex
Community health care related deaths; Emergency services related deaths (2019 onwards)
Worthing Homes; South East Coast Ambulance Service; NHS Pathways
23/09/2013
2013-0196
Sally King
Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Care Quality Commission
26 October 2021
2021-0361
Christopher Collinson
Birmingham and Solihull
Hospital Death (Clinical Procedures and medical management) related deaths |�Alcohol, drug and medication related deaths
University Hospitals Birmingham NHS Foundation Trust
26 October 2021
2021-0359
Kyle Hurst
North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths | Suicide (from 2015) |�Wales prevention of future deaths reports (2019 onwards)
Betsi Cadwaladr University Health Board
28 June 2021
2021-0360
Nicholas Spooner
Brighton and Hove
Mental Health related deaths
NHS Brighton and Hove Clinical Commissioning Group | Brighton and Hove City Council | Sussex Partnership Foundation Trust | Change Grow Live (Surrey and Borders NHS Trust) | Department of Health and Social Care
28 May 2020
2020-0122
Michael Pender
Cornwall and the Isles of Scilly
Other related deaths
Department for Transport | Maritime and Coastguard Agency | Royal National Lifeboat Institute
7 August 2020
2020-0152
Jan Klempar
Cornwall & Isles of Scilly
Other related deaths
Royal National Lifeboat Institution; Maritime Coastguard Agency
22 June 2020
2020-0133
Bethan Harris
West London
Hospital death (Clinical procedures and medical management) related deaths; Child death
St. George�s University Hospitals NHS Foundation Trust
26 June 2020
2020-0134
Gary Etherington
Inner South London
Mental Health related deaths; Community healthcare related deaths; Suicide
Oxleas NHS Foundation Trust
22 June 2021
2021-0212
Serena Nicolle
Surrey
State Custody related deaths
Ministry of Justice
16 July 2020
2020-0143
Kobi Wright
Norfolk
Hospital death (Clinical procedures and medical management related deaths; Child death
James Paget University Hospital | RadcliffesLeBrasseur LLP
21 August 2020
2020-0162
Malyun Karama
Inner North London
Hospital death (Clinical procedure and medical management) related deaths
Royal Free Hospital
17 July 2020
2020-0144
Jerrelle McKenzie
Bedfordshire and Luton
Alcohol, drug and medication related deaths
Department for Digital, Culture, Media and Sport
29 June 2021
2021-0222
Katie Locke
Hertfordshire
Hospital Death (Clinical Procedures and medical management) related deaths | Other related deaths | Police related deaths | Mental Health related deaths
National Probation Service | Hertfordshire Partnership University NHS Foundation Trust | Hertfordshire Constabulary
7 August 2020
2020-0153
Anthony Williamson
Cornwall & Isles of Scilly
Other related deaths
Royal National Lifeboat Institution; Maritime Coastguard Agency
8 September 2020
2020-0172
Linda Phillipson
Brighton and Hove
Hospital death (Clinical procedures and medical management) related deaths
Western Sussex Hospital Trust
10 August 2020
2020-0154
Francis Cooney
Birmingham & Solihull
Suicide; Community healthcare related deaths
University Hospitals Birmingham NHS Foundation Trust
8 July 2021
2021-0232
Nadeem Ahmed
East London
Emergency services related deaths (2019 onwards)
London Ambulance Service NHS Trust | London�s Air Ambulance
26 August 2020
2020-0164
Toby Nieland
Lincolnshire
Alcohol, drug and medication related deaths; Community healthcare related deaths; Mental health related deaths
South Lincolnshire Clinical Commissioning Group; Lincolnshire County Council; We Are With You charity; Lincolnshire Partnership NHS Foundation Trust
18 August 2020
2020-0163
Viktor Scott-Brown
County Durham and Darlington
Suicide; Community healthcare related deaths
National Institute for Health and Care Excellence | South London and Maudsley NHS Foundation Trust | Oxleas NHS Foundation Trust | Informa Healthcare | Tees, Esk and Wear Valleys NHS Foundation Trust
2 March 2020
2020-0142
Sophie Boothe
Hampshire (Central)
Mental Health related deaths; Alcohol, drug and medication related deaths
Berkshire Healthcare NHS Foundation Trust
23 September 2020
2020-0182
Andres Roberts
Swansea and Neath Port Talbot
Emergency services related deaths; Wales Prevention of Future Death Reports
Welsh Ambulance Services NHS Trust; Department for Health and Social Care
27 January 2020
2020-0124
Shant� Turay-Thomas
Inner North London
Emergency services related deaths; Community healthcare related deaths; Other related deaths
Winchmore Hill Practice; Enfield Clinical Commissioning Group; Bausch & Lomb UK Ltd; Medicines & Healthcare Products Regulatory Agency; London Central & West Unscheduled Care Collaborative; Advanced Health & Care Ltd; London Ambulance Service NHS Trust; Association of Ambulance Chief Executives; NHS Digital; NHS England & NHS Improvement; National Institute for Health & Care Excellence; Department of Health & Social Care
29 May 2020
2020-0115
Flora Shen
London; Inner North London
Railway related deaths
The Office of Rail & Road; Transport for London; Train Services, DLR
24 April 2020
2020-0104
Dean George
Swansea and Neath Port Talbot
Alcohol, drug and medication related deaths; State Custody related deaths; Suicide; Wales prevention of future deaths reports
Department of Health
12 May 2021
2021-0162
Steven Oscroft
Nottingham City and Nottinghamshire
Other related deaths | Road (Highways Safety) related deaths
Paul Wainwright Construction Services Ltd | Driver and Vehicle Licensing Agency
17 September 2019
2019-0507
Jonathan Ball
West Yorkshire (East)
Road (Highways Safety) related deaths
Road Haulage Association; DAF Trucks Ltd; Whitelock Development; Office of the Traffic Commissioner
22 October 2019
2019-0506
Lauren Finch
Manchester West
Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths; Suicide (from 2015);
North West Boroughs Healthcare NHS Foundation Trust
29/05/2020
2020-0114
Omarian Brooks
London Inner South
Community healthcare related deaths
London Ambulance Service NHS Trust | Lewisham Council | Sydenham Green Group General Practice | Lewisham & Greenwich NHS Trust
15 December 2020
2021-0172
Don Fernandes
Oxfordshire
Child Death (from 2015) |�Hospital Death (Clinical Procedures and medical management) related deaths
Oxford University Hospitals NHS Foundation Trust
28 May 2021
2021-0182
Peggy Copeman
Norfolk
Emergency services related deaths (2019 onwards)
Premier Rescue Ambulance Services
4 June 2021
2021-0192
David Ormesher
City of Brighton and Hove
Police related deaths |�Road (Highways Safety) related deaths
Sussex Police | National Police Chiefs� Council
15 April 2020
2020-0097
Millie Taylor-Noonan
Lincolnshire
Road (Highways Safety) related deaths
Lincolnshire County Council Highways Department
14 June 2021
2021-0202
Ian Hall
Greater Manchester South
Community health care | Other related deaths |�Alcohol, drug and medication related deaths
Medicines and Healthcare Products Regulatory Agency | NHS Stockport Clinical Commissioning Group
22 April 2020
2020-0098
Norman Baxter
Manchester South
Care home health related deaths
Lynmere Nursing home
24 April 2020
2020-0105
Mary Brady
Greater Manchester South
Care Home Health related deaths; Mental Health related deaths; Other related deaths
Care Quality Commission (CQC); Department of State for Social Care
28 May 2020
2020-0121
Gillian Davey
Cornwall and the Isles of Scilly
Other related deaths
Department for Transport | Maritime and Coastguard Agency | Royal National Lifeboat Institute
27 April 2020
2020-0106
Evelyn Ross
Greater Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths; Other related deaths
Manchester University Foundation Trust (MFT); Department of Health and Social Care
5 February 2020
2020-0116
Adam Bojelian
West Yorkshire (East)
Child Death (from 2015); Other related deaths
Leeds Teaching Hospitals NHS Trust
25 June 2020
2020-0132
Winifred (Mary) Redfearn
Wiltshire and Swindon
Hospital death (Clinical procedures and medical management) related deaths
The Great Western Hospital NHS Foundation Trust
07/05/2020
2020-0084
Vhari Ingall and Mary Johnson
Wiltshire and Swindon
Emergency services related deaths (2019 onwards) | Alcohol, drug and medication related deaths
These reports are being sent to: South Western Ambulance Trust | Association of Ambulance Chief Executives | CQC | Department of Health and Social Care
14 July 2021
2021-0242
Rhian Roberts
North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths |�Wales prevention of future deaths reports (2019 onwards)
Betsi Cadwaladr University Health Board
9 September 2020
2020-0173
Frederick Terry
Essex
Child death; Hospital death (Clinical procedures and medical management) related deaths
Mid and South Essex NHS Foundation Trust
5 November 2020
2020-0223
Ann Smith
Essex
Hospital Death (Clinical Procedures and medical management) related deaths | Other related deaths
Princess Alexandra Hospital
2 September 2021
2021-0292
Harold Blackshaw
Stoke-on-Trent & North Staffordshire Coroner�s Court
Hospital Death (Clinical Procedures and medical management) related deaths
Haywood Hospital and NHS England
12 November 2020
2020-0234
Imane Bouasbia
East London
Suicide (from 2015) |�Police related deaths
Home Office and Metropolitan Police
23 November 2020
2020-0253
Claire Richards
County Durham and Darlington
Mental health related deaths; Alcohol, drug and medication related deaths
Royal Pharmaceutical Society and Advisory Council on the Misuse of Drugs � Home Office
10 September 2021
2021-0302
Barry Martin
Manchester South
Community health care |�Other related deaths
Jigsaw Homes Tameside
10 November 2020
2020-0235
Ewan Brown
Newcastle upon Tyne and North Tyneside
Police related deaths | Mental Health related deaths | Community health care related deaths | Other related deaths
Northumbria Police, Newcastle City Council, St. Nicholas Hospital and House of Commons
16 November 2020
2020-0244
Daniel Bancroft
Cumbria
Road (Highways Safety) related deaths
Highways England Co. Ltd and Cumbria County Council (Highways)
26 November 2020
2020-0254
Eleanor Sherman
Warwickshire
Community healthcare related deaths; Hospital death (Clinical procedures and medical management) related deaths
Warwick Hospital
06/12/2022
2022-0393
Daniel Tilley
Cornwall and the Isles of Scilly Category: Suicide (from 2015) This report is being sent to: Devon and Cornwall Constabulary
Devon and Cornwall Constabulary
Suicide (from 2015)
25/11/2022
2022-0385
Ann Daghlian
North Wales East and Central Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: TLC Nursing and Care
TLC Nursing and Care
Hospital Death (Clinical Procedures and medical management) related deaths
08/12/2022
2022-0394
Leanne Dunn
County Durham and Darlington Category: Suicide (from 2015) This report is being sent to: �Durham County Council
�Durham County Council
Suicide (from 2015)
16/12/2022
2022-0403
Zef Eisenberg
North Yorkshire and City of York Category: Other related deaths This report is being sent to: Regulatory Counsel and Disciplinary Officer
Regulatory Counsel and Disciplinary Officer
Other related deaths
08/12/2022
2022-0395
Tracy Brown
Hampshire, Portsmouth and Southampton Category: Alcohol, drug and medication related deaths This report is being sent to: REDACTED
REDACTED
Alcohol, drug and medication related deaths
13/12/2022
2022-0404
Yvonne Rankin
South Wales Central Category: Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Cardiff and Vale University Health Board NHS Trust and Abbott Nutrition
Cardiff and Vale University Health Board NHS Trust and Abbott Nutrition
Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards)
16/12/2022
2022-0405
Jack Knapman
Northamptonshire Category: Alcohol, drug and medication related deaths This report is being sent to: Home Office
Home Office
Alcohol, drug and medication related deaths
02/02/2023
2023-0045
Mary White
Gwent
INVESTIGATION AND INQUEST On an investigation was opened on 22 June 2021 into the death of Mary Doreen White. The investigation concluded at the end of the inquest on: 5 July 2022. The conclusion of the inquest was recorded as: Accident. The medical cause of death was: 1 a Chest Infection b Osteoporotic fracture of right neck of femur (operated) and Chronic Obstructive Pulmonary disease � II. Frailty of Old Age
Mrs White was a lady of advancing years, who had a number of increasing health concerns. She was admitted into Ysbyty Ystrad Fawr on 5 April 2021. Whilst she was an inpatient she had three falls. The first fall caused superficial head injury, the second fall caused a right fractured neck of femur and the third caused Mrs White to suffer a moderately displaced intertrochanteric fracture of the right proximal femur. Following the third fall she underwent surgery at the Grange University Hospital but when recovering from that surgery her condition deteriorated and she died. � Box 3 of the Record of Inquest reads: � Mary Doreen White was admitted to hospital in April 2021. She fell in hospital and suffered traumatic injury which required surgery. Whilst recovering she developed a chest infection from which she could not recover. Her condition deteriorated and she died on 9 July 2021 at Ysbyty Ystrad Fawr.
COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) ������� The family of Mrs White � I am also under a duty to send the Chief Coroner a copy of your response. The Chief coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief coroner.
Wales prevention of future deaths reports (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths
N/A
26/06/2024
2024-0340
Nicola Lacey
Herefordshire
On 13 January 2023 I commenced an investigation into the death of Nicola Jane LACEY. The investigation concluded at the end of the inquest on 12 June 2024. The conclusion of the inquest was suicide.
Nicola Jane Lacey lived alone in a large property in rural Herefordshire. She had recently separated from a partner. On the 30th December 2022, the deceased did not attend work and did not call anyone. This raised concern. As a consequence a member of staff who worked with the deceased attended her address. There was no answer at the address and therefore the Police were called. Police attended the scene and forced entry. The Police established that Nicola Jane Lacey had died. A note identified the deceased�s intentions. � Nicola Jane Lacey had a responsible position within Healthcare.
I have sent a copy of my report to the Chief Coroner . � I am also under a duty to send the Chief Coroner a copy of your response . � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner , at the time of your response, about the release or the publication of your response by the Chief Coroner.
Suicide (from 2015) This report is being sent to: Herefordshire and Worcestershire Health and Care NHS Trust.
25/03/2024
2024-0449
Alexander Lyalushko
Nottingham and Nottinghamshire
On 12 March 2023, I commenced an investigation into the death of Alexander Vitali Lyalushko. The investigation concluded at the end of the inquest on 15 March 2024. The conclusion of the inquest was suicide.
Mr Lyalushko took his own life by hanging, intending to end his life, on 2 January 2023. Mr Lyalushko died at his home address where he lived alone. My Lyalushko was a vulnerable young man with diagnoses of autistic spectrum disorder, anxiety, depression and agoraphobia. Mr Lyalushko was known to express suicidal ideation and had made suicide attempts. Mr Lyalushko had extensive involvement with mental health services throughout his life, including with Gedling Local Mental Health Team under Nottinghamshire Healthcare NHS Foundation Trust from August 2015 to August 2019, and from July 2020 to March 2022. A request for the involvement of Gedling Local Mental Health Team with Mr Lyalushko was sent to the service by Mr Lyalushko�s General Practitioner on 22 November 2022. For reasons which have not been ascertainable, no action was taken in response to that request. Mr Lyalushko took his own life a little over a month later, there being no involvement of mental health services with him at the time of his death. Detailed findings as to how Mr Lyalushko came by his death are described within a written determination dated 15 March 2024, appended to this report
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. Mr Lyalushko�s family I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I will send a copy of my report to the Care Quality Commission. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.
Suicide (from 2015)
Nottinghamshire Healthcare NHS Foundation Trust
22/08/2024
2024-0467
Elise Walsh
Northumberland
Suicide (from 2015)
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
30/07/2013
2013-0175
Derek Edward Bartlett Twivey
West Sussex
Community health care and emergency services related deaths
Fairlight Nursing Home
21/08/2013
2013-0213
John Walker
West Sussex
Mental Health related deaths
Sussex Partnership NHS Trust
14/11/2013
2013-0299
Dean Griffiths
Kent (Central & South East)
Other related deaths
This is being sent to: Ministry of Defence
10/09/2013
2013-0346
David Douglas Hackman
Wiltshire & Swindon
Hospital Death (Clinical Procedures and medical management) related deaths
NHS England
09/08/2013
2013-0181
Ronald Sherlock
Norfolk
State Custody related deaths
Serco Group
12/10/2013
2013-0183
Carol Ann Gibson
Cheshire
Community health care and emergency services related deaths
NHS England | Castlefields Health Centre
23/09/2013
2013-0195
Yvonne Sydney Annie Perry
Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Care Quality Commission
bottom of page