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Coroner’s reportPrevention of future deaths · 2019-0403

Hospital Death (Clinical Procedures and medical management) related deaths

Dated 28 Nov 2019, from the coroner for Wiltshire and Swindon. Sent to 2 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

How this works

The 56-day response deadline

Deadline passed

Replies were due by 23 Jan 2020. 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.

  1. Report dated28 Nov 2019
  2. Deadline23 Jan 2020
  3. Published on judiciary.uk29 Dec 2019
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
National Institute for Health and Care ExcellenceDeadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 Jan 2020. A reply may have been sent and not yet published.
Avon and Wiltshire Mental Health Partnership NHS TrustNamed in the report as “Avon and Wiltshire Mental Health NHS Trust”Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 23 Jan 2020. A reply may have been sent and not yet published.

The coroner’s concerns

Read the coroner’s concerns in the full report on judiciary.uk.

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, 2019-0403
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

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