Berkshire
Coroner Area
Reports: 75
Earliest: Nov 2013
Latest: 30 Mar 2026
81% response rate (above 63% average).
Francis Barnes
All Responded
2023-0417
27 Oct 2023
Oxford University Hospitals NHS Foundat…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.
Action Taken
(AI summary)
Oxford University Hospitals updated their Mortality Review Policy to include an appendix on cross-system learning responses and established a weekly Patient Safety meeting with the Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care Board (ICB).
Devon Turner
All Responded
2023-0353
18 Aug 2023
Berkshire Integrated Care Board
Medication and Healthcare Products Regu…
Medtronic
+2 more
Child Death (from 2015)
Concerns summary (AI summary)
Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents to critical oxygen drops.
Disputed
(AI summary)
NHS England shared the report with patient safety and children & young people's teams and is in contact with the MHRA regarding the concerns raised about the SATS machine. Regional colleagues are engaging with Berkshire Integrated Care Board (ICB) to ensure learnings are acted upon. Medtronic believes the PM100N device was functioning appropriately, accurately recording data, and suitable for home use, so no modification or change is required. Buckinghamshire Oxfordshire and Berkshire West ICB held a Joint Agency Response meeting and a Child Death Review meeting with partner organisations and sought clarification from Berkshire Healthcare NHS Foundation Trust regarding the equipment provided. Berkshire Healthcare NHS Foundation Trust confirms that all equipment supplied to Devon had been checked by the CCN before allocation, all were within their service dates and had been serviced annually as per manufacturers guidelines.
Lucy Walles
All Responded
2023-0206
22 Jun 2023
Reading Borough Council, Berkshire Heal…
Suicide (from 2015)
Concerns summary (AI summary)
Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.
Action Taken
(AI summary)
Berkshire Healthcare NHS Foundation Trust describes the 'One Team' program to improve mental health services, including clear care plans, named workers, and connections to meaningful activities. They have implemented measures to improve staff retention and recruitment, and are participating in a Safeguarding Adults Review. Reading Borough Council has made improvements to the management of safeguarding referrals, including a dedicated safeguarding worker and adherence to Berkshire Safeguarding Policy. They have implemented a Quality Assurance Framework with an audit program for safeguarding referrals and will consider recommendations from the Safeguarding Adults Review.
Raniya Khan
All Responded
2023-0059Deceased
15 Feb 2023
Royal Berkshire NHS Foundation Trust
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Action Taken
(AI summary)
The Trust has implemented a process for storing placentas for 48 hours for histological examination, detailed in SOP MATSOP064, and has also strengthened the Policy for feedback of concerns raised about temporary agency staff; the issue of agency staff was raised with the BOB LMNS and Regional Chief Midwife to take forward. The Trust has updated psychotherapy discharge letters to include prompts for discharge planning, requires written communication with the locality MDT team prior to the discharge of patients on Section 117 aftercare plans, and will update CPA review documentation to ensure carers are involved in the review process.
Neal Saunders
All Responded
2022-0401
15 Dec 2022
Thames Valley Police, College of Polici…
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also contains inaccurate medical information and lacks effective embedding methods, risking inappropriate officer responses.
Action Planned
(AI summary)
Thames Valley Police are designing two new SNAP Guides covering ABD and Prone Restraint to be available and disseminated by the end of February 2023, and have included guidance on managing vulnerability within PPST training. South Central Ambulance Service has met with Thames Valley Police and other organizations to review policies and training. They are drafting a directive to use the phonetic alphabet to relay medical information to minimize miscommunication with emergency services. The College of Policing is implementing a new mandatory training package for Public and Personal Safety Training (PPST), starting in April 2023, that includes de-escalation, communication skills, managing vulnerability, and dealing with medical emergencies, and will revise training to clarify guidance applicability, ambulance service response expectations, and remove references to ‘chemical sedation’.
Frederick King
All Responded
2022-0363
15 Nov 2022
Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary)
The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.
Action Taken
(AI summary)
CQC conducted follow-up inspections of Birchwood Care Home after concerns were raised and rated the home as 'requires improvement' or 'inadequate' in several domains. They are keeping the service under review and will conduct another comprehensive inspection by August 2023, and will consider enforcement action based on the circumstances leading to the death.
Adele Massoudi
All Responded
2022-0185
20 Jun 2022
Royal Berkshire NHS Foundation Trust
Child Death (from 2015)
Community health care and emergency services related deaths
Concerns summary (AI summary)
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta was not retained, hindering vital examination for learning.
Action Taken
(AI summary)
Royal Berkshire NHS Foundation Trust commissioned an external midwifery report and is developing an action plan to address recommendations for future training provision. A new SOP provides guidance on placenta histology, storage, and retention, and all Band 7 midwives and Unit Coordinators will be trained on the new SOP.
Zoltan Torok
All Responded
2022-0088
21 Mar 2022
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes and confusion from mixing smart and traditional motorways.
Action Taken
(AI summary)
National Highways states that the section of motorway was under temporary traffic management and not operating as a smart motorway at the time of the incident, so they do not believe any additional actions are needed, but they have completed the roll-out of stopped vehicle detection on over 200 miles of ALR motorway, installed extra signs, and upgraded enforcement cameras. They also committed to deliver a £390 million programme to install additional emergency areas across operational sections.
Jordan Mhlanga-Veira
All Responded
2021-0403
26 Nov 2021
Environment Agency and National Trust
Child Death (from 2015)
Other related deaths
Concerns summary (AI summary)
Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used for tidal waters.
Noted
(AI summary)
The National Trust will conduct an immediate review of its risk assessment for Cock Marsh, including control measures and signage, and a signage pilot will commence prior to the early spring Bank Holiday to test the location, wording and effectiveness of such measures. There are plans for the Property Team to share this information Jordan's family and reviewing website visitor information. The Environment Agency acknowledges the coroner's concerns regarding safety measures at a specific site, but states that the National Trust, as landowner, holds primary responsibility for implementing measures like warning signs and rescue devices. The EA outlines its responsibilities as the navigation authority for the River Thames and its regular inspection of assets, but refers to case law indicating individuals should take responsibility for their own safety during potentially dangerous activities.
Joel Robinson
All Responded
2021-0398
25 Nov 2021
Army Headquarters
Mental Health related deaths
Service Personnel related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command were identified.
Action Planned
(AI summary)
The Army outlines several actions planned or underway, including establishing a dedicated sub-group by March 2022 to improve information sharing processes and the MOD developing a Defence Suicide Prevention Plan with an initial draft to be produced by the summer. It is also testing a pilot scheme to provide virtual means of reporting a complaint.
Aston McLean
All Responded
2020-0015
20 Jan 2020
JRCALC
Emergency services related deaths (2019 onwards)
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of fire service capabilities for vehicle lifting, hindering decision-making.
Action Planned
(AI summary)
The Association of Ambulance Chief Executives is reviewing the JRCALC clinical practice guidelines in relation to recognition of life extinct (ROLE). They will amend the wording to clarify what to do when access to the patient is not possible and to clarify the need to work with other agencies.
Catherine Gardiner, Jason Aleixo, Lorraine Maclellan
All Responded
2019-0350
24 Oct 2019
Ford UK
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and the manufacturer has yet to conduct a forensic examination to identify relevant faults.
Noted
(AI summary)
Highways England acknowledges receipt of the report and briefly summarises their procedures for temporary road closures, stating that closures are kept to the shortest time possible and safety is prioritised. Ford acknowledges the report and emphasises their commitment to customer safety and quality control, highlighting their monitoring and improvement processes, but doesn't commit to any specific action as a result of this case. Highways England clarifies the oversight role of the Department for Transport (DfT) and Office of Road and Rail (ORR), and explains its statutory powers regarding traffic regulation orders under the Road Traffic Regulation Act 1984. It notes the absence of incentives or penalties related to hard shoulder closures.
John Shackley
All Responded
2019-0238
12 Jul 2019
Highways Authority
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians to cross a dangerous, unlit road.
Action Planned
(AI summary)
• The Royal Borough of Windsor and Maidenhead met with the Police on 7th August 2018 to review the circumstances around the crash.
• The Highway Authority will monitor and review pedestrian activity in the area.
• There is existing street lighting on the road corresponding.
Jason Imi
All Responded
2019-0238-wp26735
12 Jul 2019
Highways Authority
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians to cross in darkness with poor visibility, creating a significant risk of collision.
Action Taken
(AI summary)
• The Highways Authority met with the Police on 7th August 2018 to review the circumstances around the crash.
• The Highways Authority will monitor and review pedestrian activity in the area.
• There is existing street lighting on the road.
Joshua Blackham
All Responded
2019-0182
31 May 2019
Surrey Police
Police related deaths
Concerns summary (AI summary)
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Action Taken
(AI summary)
Surrey Police will provide training and refreshed guidance for Welfare Officers and those who supervise them. Revised guidance has been created to include contacting the family of an officer suspended from duty, a secondary (back up) WO, and consideration about the location of the arrest of a serving officer.
June Russell
All Responded
2019-0128
17 Apr 2019
Slough Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too slowly.
Action Planned
(AI summary)
The Council has commissioned an independent road safety review of the junction and will provide a detailed report with proposals for improvements in approximately 6-8 weeks, with recommendations for short, medium, and long-term actions.
Violet Nelson
All Responded
2017-0356
7 Dec 2017
NHS England
Royal College of General Practitioners
Society of Radiographers
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.
Noted
(AI summary)
NHS England will ensure that the NICE lead for the Abdominal Aortic Aneurysm guideline is aware of the coroner's concerns and will ensure the report is considered by the working group led by the National Clinical Director for Diagnostics. The RCGP agrees GPs are unlikely to be aware that a supra-renal aortic aneurysm should raise concerns about the possibility of a thoracic aortic aneurysm; they rely on secondary care reports for recommendations about findings. The Society of Radiographers will communicate to radiology services the need for sonographers to have clear processes for arranging onward referral.
Isabella Pritchard
All Responded
2017-0261
16 Aug 2017
Department of Business, Energy and Indu…
Department of Communities and Local Gov…
Product related deaths
Concerns summary (AI summary)
The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the risk of serious incidents.
Action Planned
(AI summary)
The department will ask the Building Regulations Advisory Committee to reconsider regulating stone fire surrounds and will alert registered installers to good practice guidance. Officials will also continue working with other agencies to keep guidance up to date.
George Cheese
All Responded
2017-0179
6 Jun 2017
Woodley Centre Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary)
A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.
Action Taken
(AI summary)
The surgery introduced a policy requiring GPs only to issue repeat prescriptions and conduct depression reviews. They will also discuss the role of clinicians at a clinical meeting and arranged for a consultant psychiatrist to talk about management of mental health disorders.
Malcolm Langford
All Responded
2017-0099
31 Mar 2017
Transport Manager, Reading Borough Coun…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a critical design flaw.
Disputed
(AI summary)
The Council acknowledges changes made at the junction over the years but believes the accident was due to the driver's failure to stop, and requests clarity on the circumstances of the collision to properly ensure they meet their duty as highway authority.
Charles Rendell
All Responded
2017-0006
11 Jan 2017
Bayer Plc
Other related deaths
Concerns summary (AI summary)
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Noted
(AI summary)
Bayer states that patient safety is taken very seriously. They reviewed reports of psychiatric effects associated with ciprofloxacin and believe the UK product information includes an appropriate warning to advise prescribers and patients. The MHRA reviewed the information and considers that the product information for Ciproxin provides up-to-date information on the risk of mental disturbances. They will review all UK Package Leaflets for generic ciprofloxacin products to ensure consistent presentation of this information.
Christopher Brand
All Responded
2016-0154
21 Apr 2016
Broadmoor Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.
Action Taken
(AI summary)
West London Mental Health Trust has implemented monthly checks of observation windows on each ward, and staff have undertaken mandatory training in observation and engagement skills. They are commissioning Immediate Life Support courses and have incorporated the National Early Warning Score (NEWS) into clinical policy.
James Fyfe
All Responded
2015-0099
5 Jan 2015
Anetic Aid Limited
Medicines and Healthcare Products Regul…
Royal Berkshire Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA failed to escalate this known hazard to other hospital trusts.
Disputed
(AI summary)
MHRA has discussed the QA3 instructions for use with the manufacturer, advising them to review them again to ensure that they are still accurate and appropriate. MHRA contacted four other Hospital Trusts via our Medical Device Safety Officer (MDSO) network, each of which have over one hundred QA3 trolleys in use, to establish whether they have had this problem but had not reported it to MHRA. AneticAid defends the design and safety record of its QA3 trolley, arguing that no retrospective changes are needed. They suggest the issue is localised to Royal Berkshire Hospital and will continue to provide training and support to the hospital staff. Royal Berkshire NHS Trust has contracted with Anetic Aid (AA) to undertake periodic inspection and maintenance on all of its QA3 trolleys. The Trust has further updated its Clinical Engineering Checklist for AA QA3 trolleys to expressly detail the checks that must be undertaken during every inspection of a QA3 trolley.
Stephen Church
All Responded
2014-0331
15 Jul 2014
Berkshire Healthcare NHS Foundation Tru…
British Transport Police
Royal Berkshire NHS Foundation Trust
+1 more
Other related deaths
Concerns summary (AI summary)
A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health Act assessment for a high-risk individual.
Action Planned
(AI summary)
Thames Valley Police is coordinating the re-drafting of an interagency joint working protocol for managing mental health in the Thames Valley area, taking into account the findings of the inquest. BTP updated its Manual of Guidance to ensure detainees are not left unsupervised until formally handed over to medical professionals, and that relevant mental health professionals are advised of the person's status. They also implemented training exercises and awareness programs for officers and control room staff on vulnerable persons, suicide prevention, and mental health issues incorporating lessons from the inquest. The Trust has finalised an interagency protocol and will be sending it out to all the agencies involved for consultation and will discuss the revised protocol with training for staff involved in crisis management to follow.
Kenneth Aldridge
All Responded
2014-0071
24 Feb 2014
West Berkshire Highways Authority
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway safety risk.
Action Planned
(AI summary)
West Berkshire Council will consult with local ward members and parish councils regarding access improvements, including reducing the westbound traffic lanes and potentially blocking one service road entrance.