Wiltshire and Swindon

Coroner Area
Reports: 57 Earliest: Sep 2013 Latest: 19 Nov 2025

68% response rate (above 63% average).

Response Status
Responded 39 No Response 1 Historic 17
AI Classification
Action Taken 40%
Action Planned 44%
Noted 16%
Disputed 0%
Based on 55 classified responses
Top Categories
Hospital Death (Clinical Procedure… (16) Road (Highways Safety) related dea… (8) Suicide (from 2015) (7) Service Personnel related deaths (7) Alcohol, drug and medication relat… (6)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: -25 reports · +3pp response rate
vs national average: -27 reports · +5pp response rate
Clear 33 results
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).
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.
Robert Wood
All Responded
2014-0556-wp26758 3 Jun 2014
Ministry of Defence
Service Personnel related deaths
Concerns summary (AI summary) Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.
Action Taken (AI summary) • The Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to clarify that a competent fire risk assessor must be consulted before changes take place or if the fire risk assessment is no longer valid. • The Fire Non-Commissioned Officer (NCO) course content has been amended to allocate more time and emphasis on the fire risks associated with electrical overloading. • The DFRMO Fire Risk Assessment template has been updated to further emphasize the need to record if any sleeping is place on the premises regardless of its primary purpose.
Andrew Horgan
All Responded
2014-0163 8 Apr 2014
Great Western Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Action Taken (AI summary) The Trust increased the number of Mental Health Liaison nurses from 2.6 to 6.8 and appointed a dedicated Consultant Psychiatrist. They also state that 82% of clinical staff had undertaken Mental Health Act training and 94% MCA and DoLS during 2013/14.
Wendy Brown
All Responded
2014-0113 12 Mar 2014
Swindon Borough Council
Community health care and emergency services related deaths
Concerns summary (AI summary) Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Action Taken (AI summary) Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, the indicative budget can be agreed pending any additional information required to ensure that some services are in place in a timely manner.