Wiltshire and Swindon
Coroner Area
Reports: 57
Earliest: Sep 2013
Latest: 19 Nov 2025
68% response rate (above 62% average).
Adam Stuyvesant
Historic (No Identified Response)
2023-0372
6 Oct 2023
Great Western Hospital
Child Death (from 2015)
Road (Highways Safety) related deaths
Concerns summary
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.
Thomas Wedrychowski
Historic (No Identified Response)
2019-0403
28 Nov 2019
Avon and Wiltshire Mental Health NHS Tr…
National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
Heather Birchall
Historic (No Identified Response)
2019-0223
28 Jun 2019
Department of Health and Social Care
Alcohol, drug and medication related deaths
Concerns summary
Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.
Karen Wiggins
Historic (No Identified Response)
2018-0177
13 Jun 2018
Swindon Borough Council
Suicide (from 2015)
Concerns summary
Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
Doreen Miller
Historic (No Identified Response)
2017-0169
26 May 2017
Chippenham Community Hospital
Great Western NHS Hospital Trust
Wiltshire Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Sharon Soares
Historic (No Identified Response)
2017-0157
15 May 2017
Chief Fire Officer’s Association
Community health care and emergency services related deaths
Concerns summary
There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.
Blaise Alvares
Historic (No Identified Response)
2017-0157-wp25814
15 May 2017
Chief Fire Officer’s Association
Community health care and emergency services related deaths
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
Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.
Calam Atour
Historic (No Identified Response)
2016-0461
12 Oct 2016
National Offender Management Service
State Custody related deaths
Concerns 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.
Daniel Paylor
Historic (No Identified Response)
2016-0353
1 Jul 2016
Medicine and Health Care Products Regul…
Community health care and emergency services related deaths
Product related deaths
Concerns 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.
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
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.
Tracey Rooke
Historic (No Identified Response)
2014-0435
9 Oct 2014
Wiltshire Council
Road (Highways Safety) related deaths
Concerns 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.
Anne-Marie Katherine Ellement
Historic (No Identified Response)
2014-0181
4 Mar 2014
Provost Marshall (Army)
Service Personnel related deaths
Concerns 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
Minister of State for Victims and Sente…
Association of Chief Police Officers
Wiltshire Clinical Commissioning Group
+2 more
Other related deaths
Concerns 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.
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
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.