Milton Keynes

Coroner Area
Reports: 80 Earliest: Sep 2013 Latest: 1 Dec 2025

66% response rate (above 62% average).

Response Status
Responded 53 No Response 1 Historic 24
AI Classification
Action Taken 52%
Action Planned 26%
Noted 13%
Disputed 9%
Based on 23 classified responses
Top Categories
Hospital Death (Clinical Procedure… (32) Suicide (from 2015) (14) State Custody related deaths (11) Mental Health related deaths (11) Road (Highways Safety) related dea… (9)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: -1 reports · +6pp response rate
vs national average: -3 reports · +4pp response rate
Clear 46 results
Alana Cutland
All Responded
2020-0151 5 Aug 2020
Medicines and Healthcare Products Regul…
Alcohol, drug and medication related deaths Other related deaths
Concerns summary The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.
Thomas Smyth
All Responded
2019-0505 28 Oct 2019
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, staff training, and the methods for recording and retrieving critical data.
John Shrosbree
All Responded
2019-0260-wp26754 26 Sep 2019
Milton Keynes University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
William Vickers
All Responded
2019-0255 26 Jul 2019
HMP Woodhill South Central Ambulance Services
Emergency services related deaths (2019 onwards) State Custody related deaths
Concerns summary Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified paramedic, impacting effective communication and care.
Barbara Henderson
All Responded
2019-0180 30 May 2019
Highways England
Road (Highways Safety) related deaths
Concerns summary Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.
Douglas Minns
All Responded
2019-0052 14 Feb 2019
Milton Keynes Clinical Commissioning Gr…
Emergency services related deaths (2019 onwards)
Concerns summary The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying response times and putting vulnerable patients' lives at risk.
Neil Swaisland
All Responded
2018-0385 12 Dec 2018
Milton Keynes Clinical Commissioning Gr… Milton Keynes Council
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.
Billie Lord
All Responded
2018-0338 1 Nov 2018
Milton Keynes Clinical Commissioning Gr…
Suicide (from 2015)
Concerns summary The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.
Ayse Yalcinkaya
All Responded
2017-0422 27 Nov 2017
Highways England
Road (Highways Safety) related deaths
Concerns summary Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing traffic.
Jason Basalat
All Responded
2017-0423 27 Nov 2017
HM Courts and Tribunals Service Northamptonshire Police
State Custody related deaths
Concerns summary Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.
Peter Cotter
All Responded
2017-0388 20 Sep 2017
South Central Ambulance Service NHS Tru…
Community health care and emergency services related deaths
Concerns summary Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting the need for a review of head injury recognition protocols.
Kevin Morgan
All Responded
2017-0165 22 May 2017
Milton Keynes Council
Community health care and emergency services related deaths
Concerns summary Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack of police welfare checks, and no serious incident review to learn lessons.
William Wilkes
All Responded
2017-0161 17 May 2017
Milton Keynes University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and CCG.
Frederick Squires
All Responded
2016-0389 31 Oct 2016
N.I.C.E
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.
Ethan Johnson
All Responded
2015-0393 29 Sep 2015
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant attendance.
Lee Boden
All Responded
2015-0394 29 Sep 2015
National Probation Service
Other related deaths
Concerns summary Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new residents contributed to the death.
Victoria Rhodes
All Responded
2014-0422 30 Sep 2014
Milton Keynes Council
Road (Highways Safety) related deaths
Concerns summary High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.
Stephen Farrar
All Responded
2014-0386-wp24441 29 Aug 2014
Ministry of Justice
State Custody related deaths
Sean Brock
All Responded
2014-0381 8 Aug 2014
National Offender Management Service
State Custody related deaths
Concerns summary A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
Ross Boyd
All Responded
2014-0313 23 May 2014
REDACTED
Care Home Health related deaths
Concerns summary An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Kevin Scarlett
All Responded
2014-0174 15 Apr 2014
National Offender Management Service
State Custody related deaths
Concerns summary The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.