Milton Keynes

Coroner Area
Reports: 81 Earliest: Sep 2013 Latest: 24 Mar 2026

65% response rate (above 63% average).

Response Status
Responded 53 No Response 2 Historic 26
AI Classification
Action Taken 39%
Action Planned 38%
Noted 18%
Disputed 5%
Based on 82 classified responses
Top Categories
Hospital Death (Clinical Procedure… (32) Suicide (from 2015) (14) State Custody related deaths (12) 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 · +5pp response rate
vs national average: -3 reports · +2pp response rate
Clear 43 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 (AI 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.
Action Planned (AI summary) The MHRA reviewed evidence on doxycycline and psychotic reactions. Based on expert advice, they will request that the lead marketing authorisation holder submit a proposal by 30 November 2020 to gather further data on the risk of psychotic reactions following doxycycline.
Thomas Smyth
All Responded
2019-0505 28 Oct 2019
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Milton Keynes University Hospital NHS Foundation Trust is undertaking several actions including a full systems review, additional eCARE training for staff, and updates to the hospital's induction process. The trust also aims to improve communication between clinical teams, improve documentation and handover procedures, and investigate implementing automated alerts to lead clinicians.
John Shrosbree
All Responded
2019-0260 26 Sep 2019
Milton Keynes University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
Noted (AI summary) • The company's Clinical Application Specialist (CAS) will provide on-site training and support for a total of 4 weeks. • The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors. • The company will also deliver 'Train the Trainer' with individuals to ensure future new starters can be trained following this initial period.
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 (AI 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.
Action Taken (AI summary) HMP Woodhill updated contingency plans to expedite emergency vehicle access, including immediate contact with ambulance services, staff reporting to the prison to await the ambulance, and training for Operational Support Grades (OSGs). All Custodial Managers will have had the opportunity to test these new arrangements. CNWL NHS Trust has implemented new AEDs with data cards, introduced an Offender Care Resuscitation Review Group, and commissioned an external review of emergency response practices. A 'Train the Trainer' course was also completed to enable regular local emergency response training.
Barbara Henderson
All Responded
2019-0180 30 May 2019
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary) Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.
Action Planned (AI summary) Highways England will issue a memorandum to all Areas highlighting the importance of inspection and defect rectification for recessed gullies. Area 8 will move to the new Asset Delivery approach on 1st October 2019.
Douglas Minns
All Responded
2019-0052 14 Feb 2019
Milton Keynes Clinical Commissioning Gr…
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) The coroner raises concerns about the withdrawal of a falls service, which provided home visits to assist those who had fallen, assessing that this puts patients' lives at risk and suggests re-introducing the service due to strains on the ambulance service.
Noted (AI summary) Milton Keynes CCG describes community-based services that superseded a previous falls service, including a Home 1st Rapids service and the Staying Steady service, and asserts that these meet the original service's objectives.
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 (AI 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.
Noted (AI summary) Milton Keynes Council has a contract for counselling services in place with MIND, which will be maintained until April 2019 whilst MIND develop additional funding opportunities for their services. Milton Keynes CCG has invested year on year into Improving Access to Psychological Therapies (IAPT) service provision and invested in a Primary Care Plus (PCP) service working with general practice to provide access to specialist support for people with serious mental illness and increasing mild and moderate need in primary care.
Billie Lord
All Responded
2018-0338 1 Nov 2018
Milton Keynes Clinical Commissioning Gr…
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) CNWL Mental Health Trust has informed the CCG that they are commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes, bringing together acute wards, older adult wards and rehabilitation services. The first meeting with planners is scheduled for 28th January.
Jason Basalat
All Responded
2017-0423 27 Nov 2017
HM Courts and Tribunals Service Northamptonshire Police
State Custody related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Custody officers and staff have been reminded of guidance on completing Prisoner Escort Record (PER) forms and ensuring relevant documentation accompanies them. Contact will be made with the national police lead on Custody to suggest a review of the PER form. The court will liaise with criminal justice agencies, the Criminal Justice Liaison and Diversion Team, and Northamptonshire Healthcare NHS Foundation Trust to review procedures for sharing information about vulnerable adults remanded to prison. Legal advisers have been reminded to forward CPNI forms or suitably endorse warrants.
Ayse Yalcinkaya
All Responded
2017-0422 27 Nov 2017
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Highways England commissioned an investigation report addressing the Coroner’s concerns, the findings of which are being reviewed by the Highways England Asset Development Team to determine what action may be appropriate for further work in 2018/19. A Smart Motorway Project is also proposed.
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 (AI 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.
Noted (AI summary) NHS England (NHS Digital) acknowledges the coroner's concerns and states that NHS Pathways identifies and assesses head injuries, including whether patients are on anti-coagulant treatment. They assert that the triage in the specific case was appropriate and consistent with NICE guidelines. South Central Ambulance Service acknowledges the coroner's concerns regarding the NHS Pathways triage system but states they cannot make changes to the software. They have notified NHS Digital of the concerns and advise the coroner to redirect the report to them.
Kevin Morgan
All Responded
2017-0165 22 May 2017
Milton Keynes Council
Community health care and emergency services related deaths
Concerns summary (AI summary) There was no effective follow up by social services and the housing team, a safeguarding alert was not properly addressed, and a meeting of senior professionals was not called to consider the case; there was no Serious Incident Review after the death.
Action Planned (AI summary) The Milton Keynes Safeguarding Board will not conduct a Safeguarding Adult Review but will undertake a learning review to identify practice improvements related to concerns raised in the Regulation 28 report. The review will include analysis of case reports, consideration of areas for concern, and a Signs of Safety approach.
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 (AI 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.
Action Planned (AI summary) NICE acknowledges the lack of guidance on when to restart Warfarin after a head injury. They will consider extending the scope of their existing head injury guideline in 2017 to address this.
Lee Boden
All Responded
2015-0394 29 Sep 2015
National Probation Service
Other related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Probation Service acknowledges shortcomings in informing the deceased of his placement and will focus on earlier planning and better liaison with probation areas. It will also explore additional training options for AP staff in responding to suspected drug overdoses, including the potential administration of heroin antagonists.
Ethan Johnson
All Responded
2015-0393 29 Sep 2015
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Trust has strengthened the preceptorship period for newly qualified midwives, implemented 2-hourly 'intentional rounding' by a Band 7 Coordinator, and implemented a daily 'safety huddle' on the delivery suite.
Victoria Rhodes
All Responded
2014-0422 30 Sep 2014
Milton Keynes Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.
Action Planned (AI summary) Milton Keynes Council is undertaking a comprehensive road safety review, prompted by a rise in serious incidents, and will bear the coroner's points in mind when compiling the report. The report's recommendations are intended to help reduce risk on the road network.
Sean Brock
All Responded
2014-0381 8 Aug 2014
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary) A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
Noted (AI summary) HMP Woodhill staffing levels have been benchmarked and agreed upon, with ongoing local and national recruitment efforts to address vacancies. Information sharing between prison staff and contractors is a priority.
Kevin Scarlett
All Responded
2014-0174 15 Apr 2014
National Offender Management Service
State Custody related deaths
Concerns summary (AI 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.
Action Taken (AI summary) HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs.