Exclusive: at least 16 notices issued to prevent future deaths after inquests highlight care failures

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Coroners in England have said lessons must be learned from failings made by overstretched services that struggled to adapt during the Covid pandemic, as details of inquests into deaths only now emerge.

At the height of the pandemic, everything from mental health and coastguard services to care homes had to quickly change how they operated, and coroners across England are highlighting failures made during this time through reports that identify avoidable deaths.

Azra Hussain, 41, who died in secure accommodation in Birmingham on 6 May 2020. Two months before her death, she had been due to begin electroconvulsive therapy, but because of an administrative error the treatment was cancelled and was then no longer possible because of Covid restrictions. The inquest jury concluded that had she been given this treatment, she would probably have lived.

Ruth Jones, a frail older woman thought to have caught Covid, who died in a care home after a fall in self-isolation. A coroner said the care home was not equipped to watch Jones during her isolation but she needed to be monitored because of her risk of injury if left alone.

Anthony Williamson, an experienced sea kayaker who died on his 54th birthday after getting into difficulty. The coroner said he was concerned there was a reduced level of coastguard cover around the Cornish coastline owing to the pandemic.