Wiltshire and Swindon
Coroner Area
Reports: 57
Earliest: Sep 2013
Latest: 19 Nov 2025
68% response rate (above 63% average).
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that a competent fire risk assessor must be consulted before changes take place or if the fire risk assessment is no longer valid.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.
Anne-Marie Katherine Ellement
Historic (No Identified Response)
2014-0181
4 Mar 2014
Armed Forces Minister
Provost Marshall (Army)
Service Personnel related deaths
Concerns summary (AI summary)
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.
William Dowling & Victoria Rose
Historic (No Identified Response)
2014-0027
21 Jan 2014
Association of Chief Police Officers
British Medical Association
Firearms and Explosive Licensing Workin…
+5 more
Other related deaths
Concerns summary (AI summary)
There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public safety.
Christopher Scott
Historic (No Identified Response)
2013-0350
27 Nov 2013
House of Commons
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility to the public.
David Douglas Hackman
Historic (No Identified Response)
2013-0346
10 Sep 2013
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death by suicide.