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
81 results
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.
Colette Dunn
Historic (No Identified Response)
2018-0337 1 Nov 2018
Milton Keynes Clinical Commissioning Gr…
Suicide (from 2015)
Concerns summary (AI summary) A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Caroline Scott
Historic (No Identified Response)
2018-0155 21 May 2018
Central and North West London Hospital …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.
Philip Ashton
Historic (No Identified Response)
2018-0146 14 May 2018
PJ Care
Care Home Health related deaths
Concerns summary (AI summary) Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
Antony Coughtrey
Historic (No Identified Response)
2018-0014 15 Jan 2018
HM Inspectorate of Probation
Other related deaths
Concerns summary (AI summary) The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a procedural failure in referring licence breaches back to the Parole Board.
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.
Patricia Parker
Historic (No Identified Response)
2017-0454 24 Jul 2017
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
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.
William Wilkes
Partially Responded
2017-0161 17 May 2017
Clinical Commissioning Group for Milton… Milton Keynes University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Milton Keynes University Hospital NHS Foundation Trust has implemented a new policy, 'Patient's Choices To Avoid Long Hospital Stays', and is tracking delayed discharges daily via the Discharge Team. They participate in system-wide teleconferences and weekly length of stay meetings.
Ida Toole
Historic (No Identified Response)
2017-0146 2 May 2017
Excel Care
Care Home Health related deaths
Concerns summary (AI summary) A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.
Daniel Dunkley
Historic (No Identified Response)
2017-0147 2 May 2017
HMP Woddhill
State Custody related deaths
Concerns summary (AI summary) The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Simon Turvey
Historic (No Identified Response)
2016-0480 13 Dec 2016
National Offender Management Service Prison and Probation Ombudsman
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.
Anthony McManus
Historic (No Identified Response)
2016-0388 31 Oct 2016
Priory Group
Mental Health related deaths
Concerns summary (AI summary) The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
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.
James Flynn
Historic (No Identified Response)
2016-0390 31 Oct 2016
Oxford University Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.
Ian Brown
Partially Responded
2016-0200 26 May 2016
HMP Woodhill Minister for Prisons
State Custody related deaths Suicide (from 2015)
Concerns summary (AI summary) Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to inadequate ACCT case management.
Action Taken (AI summary) NOMS has introduced a monthly forum to monitor progress on actions taken in response to recommendations relating to recent deaths in custody, delivered case management training to 90% of managers who chair ACCT case reviews, and is implementing a system to provide each offender supported through the ACCT process with a designated case manager.
Daniel Byrne
Historic (No Identified Response)
14 Dec 2015
Ms Claire Murdoch, Chief Executive, Cen… Northwest London NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
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.
John Andrews
Historic (No Identified Response)
2014-0426 3 Oct 2014
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
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.
Peter White
Historic (No Identified Response)
2014-0395 5 Sep 2014
Milton Keynes Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Stephen Farrar
Partially Responded
2014-0386 29 Aug 2014
Ministry of Justice Secretary of State for Health
State Custody related deaths
Concerns summary (AI summary) There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk factors; there is no formal risk assessment tool available in prisons.
1 response from Greater Manchester Police