Buckinghamshire
Coroner Area
Reports: 25
Earliest: Jan 2014
Latest: 12 Feb 2026
60% response rate (below 63% average).
Barry Harmer
Response Pending
2026-0203
12 Feb 2026
Oxford Health NHS Foundation Trust
Mental Health related deaths
Concerns summary (AI summary)
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication to families of issues or obstructions to bed availability and reinforcement of safety plans should be a central feature of daily Patient Flow Meetings; it remains unclear how a lack of face-to-face psychiatric review can be escalated.
George Emmett
Partially Responded
2025-0345
8 Jul 2025
HM Prison & Probation Service
HMP Woodhill
Ministry of Justice
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
Action Taken
(AI summary)
HMP Aylesbury is reissuing Governor's Notices, providing staff briefings, issuing prompt cards, and using a colleague mentor program to reinforce emergency response protocols; HMP Woodhill provided one-to-one briefings, introduced a sign-off sheet for night OSGs, and issued a staff information notice to remind staff of medical emergency procedures and national guidance.
Sheila Nicholls
All Responded
2025-0009
7 Jan 2025
Mandeville Grange Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Action Taken
(AI summary)
Mandeville Grange Nursing Home has engaged Care4Quality to rewrite its policies, implemented Bright HR for policy distribution, transitioned training to Access Learning for Care, engaged four additional trainers, and ordered a CPR training manikin; emergency CPR drills will start within 1 month pending staff competency assessment.
Fern Foster
Partially Responded
2024-0311
7 Jun 2024
Association of Ambulance Chief Executiv…
National Ambulance Resilience Unit
NATIONAL AMBULANCE SERVICE MEDICAL DIRE…
+1 more
Suicide (from 2015)
Concerns summary (AI summary)
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes for on-scene administration, potentially preventing deaths.
Action Planned
(AI summary)
NARU will review evidence from a West Midlands Ambulance Service trial and a proposed Yorkshire Ambulance Service project at the forthcoming NARU Clinical Subgroup in September, with the aim of creating a unified trial across ambulance HART units to collate data on nitrite poisoning. NHS England describes the role of the Emergency Call Prioritisation Advisory Group (ECPAG) in managing ambulance service prioritisation, referencing the NHS Pathways product and its alignment with clinical standards. They also note that NHS Pathways enhanced the toxic ingestion template in PaCCS in 2021 to improve access to TOXBASE and that all PFD reports are discussed by a working group. AACE and NASMeD will await the outcome of the NARU clinical subgroup meeting regarding toxicological incidents and the potential role of methylene blue and look to support and improve clinical practice within all ambulance services. JRCALC have been named as an interested party into the forthcoming inquest of another tragic death from sodium nitrate poisoning.
Haik Nikolyan
All Responded
2023-0340
15 Aug 2023
Prison and Probation Service
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Action Taken
(AI summary)
HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment.
Anthony Rockall
Unknown
2023-0287
26 Jun 2023
Other related deaths
Concerns summary (AI summary)
Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls and fatal injuries.
Melsadie Parris
All Responded
2022-0390
2 Dec 2022
Buckingham Council Children’s Services
Child Death (from 2015)
Other related deaths
Concerns summary (AI summary)
Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Noted
(AI summary)
Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time and state that without new evidence, they would have no legal right to insist on a further visit.
Amanda Gibbens
Historic (No Identified Response)
2022-0061
23 Feb 2022
Oxford Health NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Mollie Dimmock
All Responded
2021-0379
9 Nov 2021
National Institute for Health and Care …
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.
Noted
(AI summary)
NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty.
Roy Morris
All Responded
2021-0094
29 Mar 2021
Oxford Health NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.
Action Planned
(AI summary)
The trust will strengthen the understanding and application of the CPA policy through a task and finish group of clinicians, who will review the role of the Care Coordinator and review standard operating procedures. They are also embedding the six principles of the Triangle of Care, using better lives assessments and carers’ assessments.
Heather Planner
Historic (No Identified Response)
2019-0490
13 Dec 2019
Carewatch
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider created significant medication error risks.
Alf Rewin
All Responded
2019-0469
7 Oct 2019
NHS Pathways
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
No specific safety concerns were identifiable from the provided administrative text.
Action Planned
(AI summary)
NHS Digital is requesting that ambulance trusts review their internal assurance processes regarding the management of patients who have self-harmed. NHS Digital agreed that all services should review the identification and management of these patients to ensure they are receiving the correct type of response and timely clinical assessment.
Jaspal Singh Bahra
All Responded
2019-0160
17 May 2019
Civil Aviation Authority
Other related deaths
Concerns summary (AI summary)
Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the 'See and Avoid' procedure, which poses a safety risk.
Action Planned
(AI summary)
The Civil Aviation Authority will consider the merits of additional information on best practice CO contamination avoidance, in a ‘Safety Notice’ publication and will consult with stakeholders in making this decision by the end of Q3 2019.
Emma Butler
All Responded
2019-0133A
12 Apr 2019
Oxford Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.
Action Taken
(AI summary)
The Trust has already implemented measures like case discussion groups and reflective practice groups run by psychotherapists. They also have MDT handovers every morning and provide more access to psychological therapies. The ward also considers the admission of EUPD patients carefully.
Joyce Long
Historic (No Identified Response)
2018-0406
24 Dec 2018
Buckinghamshire Healthcare NHS Trust
South Central Ambulance Service
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient deterioration.
Lewis Colgan
Historic (No Identified Response)
2018-0161
9 May 2018
Oxford Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Helen Bannister
Historic (No Identified Response)
2017-0255
29 Sep 2017
Fremantle Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.
Arthur Morley
Historic (No Identified Response)
2017-0106
4 Apr 2017
HMP Grendon
State Custody related deaths
Concerns summary (AI summary)
The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
Jack Portland
Partially Responded
2017-0049
21 Feb 2017
Central and North West Hospital NHS Tru…
HMP Woodhill
Oxford Health NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
State Custody related deaths
Concerns summary (AI summary)
No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Action Taken
(AI summary)
Extensive suicide and self-harm prevention training has been delivered to staff since 2015, new procedures have been introduced to improve ACCT management, prisoners will be able to register with a GP practice before leaving prison from July 2017, and future disclosure to the Coroner's Court will be done through GLD. The Section 17 leave form has been amended, and a new SOP for managing leave includes discussions with family. The Trust also reports on weekly monitoring processes and has introduced the appointment of a Named Professional to offer support and guidance to families.
Stephen Bird
All Responded
2016-0265
22 Jul 2016
BMI The Shelburne Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
Action Taken
(AI summary)
South Buckinghamshire Hospitals has taken several actions including re-auditing patient records, implementing mandatory training on documentation, and introducing a monthly audit of discharge documentation; a RCA report was also completed.
Robert Hogg
All Responded
2015-0313
6 Aug 2015
Department of Health and Social Care
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.
Disputed
(AI summary)
The Department of Health acknowledges the coroner's concerns and provides context about NHS Pathways and SCAS, deferring to the NHS Pathways response for specific actions. NHS Pathways disputes the coroner's concerns, arguing that the system was used correctly and that no similar cases had been reported. They request the allegations be struck from the record and seek opportunity to answer directly in similar cases.
Peter Mackie
All Responded
2014-0528
5 Dec 2014
Springhill Prison
State Custody related deaths
Concerns summary (AI summary)
Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.
Action Planned
(AI summary)
HMP Grendon and Springhill are working to increase the number of trained first aid staff, a new risk assessment will be completed to ensure appropriate levels of staff are identified to provide 24 hour cover and staff will receive written advice on when to commence CPR by 31 January 2015.
Molly Keen
Historic (No Identified Response)
2014-0336-wp24459
22 Jul 2014
West Hertfordshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications of below-normal growth, no referral for further specialist opinion or scan was made.
Richard Jaeger-Forzard
All Responded
2014-0246
30 May 2014
Terex Global Gmbh
Other related deaths
Concerns summary (AI summary)
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Action Taken
(AI summary)
Genie issued a mandatory Safety Notice requiring recalibration of Z135/70 machines and updated controller software to prevent instability due to miscalibration.
Shaun Elliott
Historic (No Identified Response)
2014-0042
31 Jan 2014
College of Policing
Community health care and emergency services related deaths
Concerns summary (AI summary)
The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed a number of concerns and frustrations in regard to family liaison, and that the definition of 'High Risk' was not clearly applied.