Coroner’s reportPrevention of future deaths · 2023-0457

Hospital Death (Clinical Procedures and medical management) related deaths

Dated 17 Nov 2023, 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.

The 56-day response deadline

All responses published

Replies were due by 12 Jan 2024.

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; a reply may have been sent and not yet published.

Report dated17 Nov 2023
Deadline12 Jan 2024
Published on judiciary.uk22 Nov 2023
Today23 Oct 2026

Watch this report

We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.

Responses from each recipient

Responses from each recipient
Sent to	Response	Published response
Great Western Hospitals NHS Foundation TrustNamed in the report as “The Great Western Hospital”	Response publishedPublished on judiciary.uk in November 2023. Read the response from Great Western Hospitals NHS Foundation Trust on judiciary.uk	Read the response from Great Western Hospitals NHS Foundation Trust on judiciary.uk
Department of Health and Social Care	Response publishedPublished on judiciary.uk in November 2023. Read the response from Department of Health and Social Care on judiciary.uk	Read the response from Department of Health and Social Care on judiciary.uk

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, 2023-0457
Added to Minute Book: 8 Oct 2026
Reuse: We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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

Ask about this report

Summaries and questions, with page references. Pro and above.