Berkshire
Coroner Area
Reports: 75
Earliest: Nov 2013
Latest: 30 Mar 2026
81% response rate (above 63% average).
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.
Leroy Medford
Partially Responded
2019-0233
9 Jul 2019
College of Policing
National Police Chiefs’ Council
Thames Valley Police
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer to be within the cell with a detained person, and recommends a national review of how training is delivered and monitored within the police service.
Action Planned
(AI summary)
Thames Valley Police have initiated a quarterly Drug Concealment Working Group and are refreshing guidance for superintendents on managing drugs concealment cases (target Nov 2019). They are developing healthcare pathways and simpler guidance, accessible on officer's mobile phones. Special Points of Contact (SPOCs) have been introduced to improve communication of new guidance. The NPCC is closely involved in the College of Policing’s work on a national strategy for police learning, which may address concerns around training. The NPCC has shared the coroner's report with chief constables, encouraging them to review training delivery within their own forces.
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.
Simon Healey
Partially Responded
2018-0378
6 Dec 2018
Independent Healthcare Providers Network
Ramsay Healthcare UK
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering their limited critical care capacity. Nursing staff on general wards may lack experience in managing post-operative complications like leaks or sepsis.
Noted
(AI summary)
The IHPN acknowledges the coroner's concerns, states that all IHPN board members have been made aware and highlights the competency and training of nursing staff in the independent sector and notes the shift to more openness and transparency with whistleblowing policies and training.
Michelle Roach
Historic (No Identified Response)
2018-0302
28 Nov 2018
Royal Berkshire Hospital
Waterfield Practice
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
Anne Roberts
Historic (No Identified Response)
2018-0321
18 Oct 2018
NHS Professionals Limited
Prospect Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.
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.
Benjamin Wylie
Partially Responded
2016-0407
14 Nov 2016
Federation of Piling Specialists
Health and Safety Executive
Soilmec Limited
Product related deaths
Concerns summary (AI summary)
Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.
Action Planned
(AI summary)
The HSE will issue a Safety Alert regarding the risks associated with grease being expelled from grease nipples at high pressure, the risks associated with the re-use of damaged hydraulic components, and the need for proper training of persons required to undertake track tensioning.
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.
Philmore Mills
Partially Responded
2016-0110
17 Mar 2016
College of Policing
National Police Chiefs’ Council
Police related deaths
Concerns summary (AI summary)
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
Action Planned
(AI summary)
The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a risk of death, within the next scheduled update.
Michael Quinn
Historic (No Identified Response)
2015-0304
3 Aug 2015
other private hospitals that utilise si…
Royal Berkshire Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Chandni Nigam
Historic (No Identified Response)
2015-0180
11 May 2015
Berkshire Healthcare NHS Foundation Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, missing potentially helpful treatment guidance.
Darren Linfoot
Historic (No Identified Response)
2015-0089
9 Mar 2015
West London Mental Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.
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.
Michael Warren
Historic (No Identified Response)
2014-0330
17 Jul 2014
Bracknell Forest Borough Council
Chartered Institute of Highways and Tra…
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" inspections, increasing risk to road users.
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.
Christine Nutbeam
Historic (No Identified Response)
2014-0025
21 Jan 2014
St Peter’s Hospital
Wexham Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.
Edna Elsie Mary Eden
All Responded
2013-0317
27 Nov 2013
Wexham Park Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Action Planned
(AI summary)
The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage bleeps and referrals, and allocate jobs to doctors.