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Stephen Bird

22 Jul 2016 · Coroner Crispin Butler · Buckinghamshire
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The coroner's concerns

  1. 1. incomplete inconsistent conflicting patient records

    “The patient records, the documentation of consultations, clinical decisions, changes to previous assessment decisions and the discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the Inquest hearing.”

  2. 2. assumptions in SCI report conflict with documentary records

    “Evidence given regarding the investigation by the hospital into Mr [name redacted] death and the preparation of a draft Significant Clinical Incident Investigation (SCI) Report (disclosed as part of the Inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the Inquest hearing.”

Responses

2016-0265-Response-by-South-Buckinghamshire-Hospitals.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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