Norfolk’s coroners issued twice as many 'preventing future deaths reports' last year, figures have revealed.
The reports are issued to people or organisations like the NHS, local authorities or government departments where coroners feel action should be taken to prevent the risk of people being killed.
In Norfolk 14 were issued in 2022, double the number the previous year and twice the number of any other coroners office in the east of England.
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Among the organisations they were issued to were the East of England Ambulance Service following the deaths of two women after delays in being transferred between two hospitals just a mile apart.
Another was sent to Great Yarmouth Borough Council and Caister-On-Sea Parish Council following the death of Coastwatch volunteer Anthony Rode who suffered injuries when he fell onto a concrete path while strimming grass on sand dunes.
Senior coroner Jacqueline Lake raised concern that a dispute between the two councils had left Mr Rode to carry out the work when it was unsafe to do so.
Other prevention of future death reports were sent to Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Norfolk and Norwich and Queen Elizabeth hospitals, and a number of care homes.
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In total there were 3,304 deaths reported to coroners in Norfolk last year, up from 2,976 seen in 2021, Home Office data shows.
Post-mortem examinations were carried out in half of deaths reported and in total 685 inquests were opened.
Natural causes was the most common verdict being reached in 153 deaths, followed by misadventure in 121 cases, 76 deaths from drugs or alcohol, 52 suicides, 46 due to industrial disease, and 19 in road traffic accidents.
Open verdicts were reached in 25 inquests, while in 179 there were other conclusions, including narrative verdicts.
The average time taken to process an inquest was 28 weeks lower than the regional average of 35 weeks.
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