“Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP…”
Dated 11 Jan 2016, from the coroner for Wiltshire and Swindon. Sent to 1 organisation or person.
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 7 Mar 2016. 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 dated11 Jan 2016
- Deadline7 Mar 2016
- Published on judiciary.uk11 Jan 2016
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Great Western Hospitals NHS Foundation TrustNamed in the report as “Great Western Hospital NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Mar 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223 This patient was prescribed steroids appropriately but the nursing staff failed to notice a dose of steroids had been missed. There is no system on the paper drug chart or the electronic prescribing system for alerting medical staff to patients being on long term steroids.
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, 2016-0013
- 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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