Berkshire

Coroner Area
Reports: 74 Earliest: Nov 2013 Latest: 27 Nov 2025

82% response rate (above 62% average).

Response Status
Responded 61 No Response 1 Historic 11
AI Classification
Action Taken 52%
Action Planned 28%
Noted 16%
Disputed 4%
Based on 25 classified responses
Top Categories
Hospital Death (Clinical Procedure… (28) Road (Highways Safety) related dea… (11) Suicide (from 2015) (10) Child Death (from 2015) (7) Other related deaths (6)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: -7 reports · +22pp response rate
vs national average: -9 reports · +20pp response rate
Clear 11 results
Jennifer Rackley
Historic (No Identified Response)
2023-0305 6 Jun 2023
Care UK
Care Home Health related deaths
Concerns summary A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.
Peter Lawrence
Historic (No Identified Response)
2023-0130 21 Apr 2023
Spire Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.
Hugo Carlos
Historic (No Identified Response)
2023-0038Deceased 1 Feb 2023
Egton Medical Information Systems
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.
James Fennell
Historic (No Identified Response)
2019-0391 19 Nov 2019
South Western Railways Office of Rail and Road
Railway related deaths
Concerns summary Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from main platform areas or tactile paving, despite high footfall and significant electrocution risk.
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 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 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.
Michael Quinn
Historic (No Identified Response)
2015-0304 3 Aug 2015
Royal Berkshire Hospital Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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 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 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.
Michael Warren
Historic (No Identified Response)
2014-0330 17 Jul 2014
Chartered Institute of Highways and Tra… Bracknell Forest Borough Council
Road (Highways Safety) related deaths
Concerns 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.
Christine Nutbeam
Historic (No Identified Response)
2014-0025 21 Jan 2014
Wexham Park Hospital St Peter’s Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.