Buckinghamshire
Coroner Area
Reports: 25
Earliest: Jan 2014
Latest: 12 Feb 2026
60% response rate (below 63% average).
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.
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.
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.
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.
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.
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.
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.