Wiltshire and Swindon
Coroner Area
Reports: 57
Earliest: Sep 2013
Latest: 19 Nov 2025
68% response rate (above 63% average).
Francis Langley
All Responded
2017-0240
4 Sep 2017
Great Western Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.
Action Taken
(AI summary)
The Trust has implemented the nursing personalised care plan documentation used at GWH on Forest and Orchard wards (SWICC) from July 2017, which includes bed rails assessment, falls assessment and a care plan.
Nina Maggs
All Responded
2017-0216
20 Jul 2017
Department for Transport
Swindon Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.
Action Planned
(AI summary)
The council will commence stakeholder consultation on 18th September 2017 regarding proposals to improve pedestrian safety at the junction. Provisional arrangements have been made to assign resources to progress with the design and potential delivery of a scheme. The Department for Transport, while noting a lack of evidence, will consider with trade associations how to encourage signage on left-hand drive vehicles to alert pedestrians to the risks.
Joyce Rumming
All Responded
2017-0182
6 Jun 2017
Great Western Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.
Action Planned
(AI summary)
The trust is working to improve the handover process with ambulance services, including plans for a new clinical note system including patient allergies. They are also exploring the IT infrastructure to improve information sharing and migrating the Emergency Department to the same server as the rest of the Trust.
Doreen Miller
Historic (No Identified Response)
2017-0169
26 May 2017
Chippenham Community Hospital
Great Western NHS Hospital Trust
Wiltshire Health & Care
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.
Blaise Alvares
Historic (No Identified Response)
2017-0157
15 May 2017
Chief Fire Officer’s Association
Community health care and emergency services related deaths
Concerns summary (AI summary)
This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also reported.
Sharon Soares
Historic (No Identified Response)
2017-0157-wp25813
15 May 2017
Chief Fire Officer’s Association
Community health care and emergency services related deaths
Concerns summary (AI summary)
There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.
Christina Witney
Historic (No Identified Response)
2017-0112
7 Apr 2017
Great Western Hospitals NHS Trust
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.
William Marson
All Responded
2016-0394
2 Nov 2016
Avon Care Home Limited
Care Home Health related deaths
Concerns summary (AI summary)
Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.
Action Planned
(AI summary)
The care home outlines a process for managing residents requiring specialist equipment or interventions, including staff training, competency assessments, clear documentation, and reviews. This process will be communicated and implemented across all Avon Care Homes.
Calam Atour
Historic (No Identified Response)
2016-0461
12 Oct 2016
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary)
Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
Miles Abel
All Responded
2016-wp25345
29 Jul 2016
Department of Health and Social Care
Endless Street Surgery
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
2 responses
from The Endless Street Doctors Surgery, Department of Health
Daniel Paylor
Historic (No Identified Response)
2016-0353
1 Jul 2016
Medicine and Health Care Products Regul…
Home Secretary, Home Office
Member of Parliament for Maidenhead, Ho…
Community health care and emergency services related deaths
Product related deaths
Concerns summary (AI summary)
Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
George Punton
All Responded
2016-0250
1 Jul 2016
Highway and Transport Wiltshire Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
No specific concerns are detailed in the provided text.
Action Planned
(AI summary)
A 20mph speed limit at Lockeridge is due to be completed by the end of 2016, including the provision of warning signs.
Robin Brett
Historic (No Identified Response)
2016-0013
11 Jan 2016
Great Western Hospital NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Tania Hristova
All Responded
2015-0392
28 Sep 2015
New Court Surgery
Community health care and emergency services related deaths
Concerns summary (AI summary)
The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
Action Taken
(AI summary)
The surgery has taken steps to ensure regular medication reviews are undertaken for patients on SSRIs and that patients are made aware of mental health support services, including raised awareness about medication review codes, a mailshot to patients, and updating the practice website.
Elizabeth Godwin
All Responded
2015-0233
19 Jun 2015
Avon and Wiltshire NHS Mental Health Pa…
Royal United Hospitals Bath NHS Foundat…
Wiltshire Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.
Action Planned
(AI summary)
Royal United Hospitals Bath NHS Foundation Trust (RUH) has implemented additional resource for Mental Health Services and amended the Mental Health Assessment Matrix. All junior doctors, Emergency Nurse Practitioners and Nursing staff receive training in the use and application of the mental health matrix at induction. Wiltshire Council describes planned discussions between Wiltshire Council (WC) and AWP to be held to clarify roles and responsibilities and ensure that a process is followed. Avon and Wiltshire NHS Trust highlights that the Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the CPA process including assessment of risk. The Trust CPA and Risk Training highlights the need for staff to include the views of service users and carers in undertaking any assessment.
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
All Responded
2015-0164
28 Apr 2015
Ministry of Defence
Service Personnel related deaths
Concerns summary (AI summary)
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
Action Planned
(AI summary)
The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System (VELS) modification, aiming for completion by the end of 2016.
Jack Rowe
Partially Responded
2015-0154
22 Apr 2015
Department for Education
Ministry of Housing, Communities & Loca…
Child Death (from 2015)
Concerns summary (AI summary)
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.
Noted
(AI summary)
The Department for Communities and Local Government does not consider building regulations to be the best way to ensure swimming pool safety, as regulations apply only where building work takes place and cannot be applied retrospectively. They expect owners/occupiers to be responsible for safety on their property.
Andrew Farrow
Partially Responded
2015-0147
20 Apr 2015
Avon and Wiltshire Mental Health Partne…
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.
Noted
(AI summary)
Avon and Wiltshire NHS Trust explains its process for managing bed pressures and out-of-area placements, stating decisions are risk-based. They also note their surprise at receiving a PFD report for an inquest where they weren't a properly interested party.
Patrick Sturtivant
Partially Responded
2015-0144
17 Apr 2015
Department for Transport
English Heritage
National Trust
+2 more
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this byway could merely shift the problem elsewhere.
Action Planned
(AI summary)
The National Trust is supportive of Wiltshire Council's proposal to downgrade a section of Byway 11 to a bridleway. They are also contributing to discussions with the Department for Transport regarding proposals for a tunnel for the A303. Wiltshire Council has commenced the process of exploring potential solutions with multiple agencies, including Highways England and Historic England. The Council has requested an extension to the response deadline to 12 months due to the multi-agency approach required. English Heritage supports the downgrading of Byway 11 to a bridleway and its closure to vehicular access, and offers to work with Wiltshire Council and the police on the matter. They acknowledge concerns about the impact on Byway 12 and that no recent action has been taken to review the use of Byways 11 or 12.
Tom Sawyer and Danny Winters
All Responded
2015-0100
16 Mar 2015
Minister of State for the Armed Forces
Service Personnel related deaths
Concerns summary (AI summary)
Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital recording for encrypted radio signals in combat scenarios.
Action Planned
(AI summary)
The MOD will investigate the inclusion of automated secure voice logs in the next generation tactical command system, with a decision expected by 2018. The Army Chief Information Officer will determine how such a capability will be used.
Richard Jones
All Responded
2015-0068
20 Feb 2015
Avon and Wiltshire NHS Mental Health Pa…
Department of Health and Social Care
Ministry of Defence
+3 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.
Noted
(AI summary)
The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, and information needs for NHS providers. It also highlights the existing out-of-hours Service Liaison Officer service and the MOD's commitment to the Mental Healthcare Crisis Concordat. The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies and procedures. The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to secure the MoD's commitment to the Mental Health Crisis Care Concordat by the end of April 2015. Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and review patients who leave before being seen, also they updated policy to inform GP if patient fails to wait for assessment. Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion with the MoD and will address the concerns raised in the report.
Mary Stroman
All Responded
2014-0454
21 Oct 2014
Haringey Council
Other related deaths
Concerns summary (AI summary)
A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory accommodation thresholds.
Action Taken
(AI summary)
Haringey Council reports strengthened management oversight of decision-making, improved joint working with partner agencies, and revised processes for funding long-term therapeutic placements. Placements are now only made in establishments graded 'good' or 'outstanding' by Ofsted, with risk assessments conducted if the grade changes.
Sapper Dylan Gibson
All Responded
2014-0436
9 Oct 2014
Ministry of Defence
Service Personnel related deaths
Concerns summary (AI summary)
The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.
Action Taken
(AI summary)
Sapper Gibson's unit now holds keys to all buildings and rooms in the guardroom. The MOD is updating its Health and Safety risk assessment guidance to ensure site risk assessments consider rapid access to locked rooms, and procedures are tested regularly; the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that master or spare keys to all rooms will be held centrally in the guardroom (or similar where there is no guardroom).
Tracey Rooke
Historic (No Identified Response)
2014-0435
9 Oct 2014
Wiltshire Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report was issued, despite earlier recommendations.
Dean Hutchinson
All Responded
2014-0556
3 Jun 2014
Ministry of Defence
Service Personnel related deaths
Concerns summary (AI summary)
The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports a preference for reviews to be undertaken before a change of use or structural alteration takes place; this wording should be reviewed.
Action Taken
(AI summary)
The Ministry of Defence has amended the Defence Fire Risk Management Organisation (DFRMO) Fire Diary, updated the Fire NCO course, and is reviewing the DFRMO Fire Risk Assessment template to emphasize recording sleeping arrangements. A Defence Instruction or Notice (DIN) has also been published covering these issues.