“It was the Jury’s determination on the evidence that the cot side was able to remain in a…”
Dated 5 Jan 2015, from the coroner for Berkshire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 2 Mar 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated5 Jan 2015
- Deadline2 Mar 2015
- Published on judiciary.uk5 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Berkshire NHS Foundation TrustNamed in the report as “Royal Berkshire Hospital Trust” | Response publishedPublished on judiciary.uk in January 2015. |
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “Medicines and Healthcare Products Regulatory Agency” | Response publishedPublished on judiciary.uk in January 2015. |
| Anetic Aid Limited | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– (1) It was the Jury’s determination on the evidence that the cot side was able to remain in a raised but unlocked position due in part to both the design and maintenance of the trolley. While evidence was given that the Trust had subsequently introduced improved service sheets and had involved the assistance of Anetic Aid Limited in maintenance, repair and training of use of the trolley, it was unclear as to whether this specific problem had been highlighted as needing careful attention in all maintenance schedules for the trolley. (2) The Jury were informed that MHRA were aware of the investigations of the incident trolley but that it did not appear that the issue had been escalated and notified to all Hospital Trusts and agencies that used this type of trolley. The MHRA’s actions in being informed of this potential hazard remain unclear, with particular reference to passing on the known risk to such trolley users. 1
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, 2015-0099
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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