“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. On the evidence I have seen from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well. 2. I have seen evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously. 3. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings. 4. There is delayed escalation of concerns. 5. Structured judgement reviews I have reviewed are at best, poor, and at worst, defensive. 6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost. 7. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable. 8. I am concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0193

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0