Oxfordshire
Coroner Area
Reports: 36
Earliest: Sep 2013
Latest: 14 Apr 2026
86% response rate (above 63% average).
John Cook
All Responded
2014-0578
9 Jun 2014
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
Disputed
(AI summary)
NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share audit results and hold the Trust to account in relation to learning from the inquest; furthermore NHS England will write to all provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England.
Peter Norman Nott
All Responded
2014-0229
28 Feb 2014
Rush Court Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Action Taken
(AI summary)
Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale and be incorporated into resident care plans; only a registered nurse or person in charge can handover clinical information to paramedics.
Clive Gould
All Responded
2013-0357
16 Dec 2013
South Central Ambulance Service NHS Fou…
Community health care and emergency services related deaths
Concerns summary (AI summary)
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Action Taken
(AI summary)
South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a Clinical Support Desk (CSD) within Emergency Operations Centre to support patients with clinical advice until a response is on scene.