Royal Berkshire Hospital

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First report 5 Jan 2015•Latest report 27 Oct 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 5
Published responses: 20%
Concerns addressed: 5
Stated actions: 5

Concerns and recipient responses

Statements from Royal Berkshire Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

27 Oct2025
Berkshire
Concerns raised1
1. Failure of obstetricians to undergo incident-derived training
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Louisa Walker · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Louisa Walker’s head was impacted in her mother’s pelvis during a caesarean section, and she suffered skull fractures and intracranial bleeding during manoeuvres to disimpact her head. She was born on 25 May 2024 and died on 28 June 2024. The principal concern was that, despite an action plan for training arising from the incident, 83% of the trust’s obstetricians had not undergone that training by the inquest.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of obstetricians to undergo incident-derived training
Wider context from the report
“1. If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death. ”
Open source report
13 Feb2024
Berkshire
Concerns raised7
1. Delays in completion of night-time blood tests
2. Lack of effective night-time Internal Escalation Policy measures
3. Delays in notification of abnormal blood test results to clinicians
1. Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
2. Lack of contemporaneous record keeping in the Emergency Department
3. Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call
4. Burdensome and time-consuming out-of-hours CT scan requesting system
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Michael James NYE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael James Nye attended the Royal Berkshire Hospital with sepsis caused by a Streptococcus A skin and soft tissue infection, but was initially diagnosed with an upper arm DVT. His condition deteriorated and he suffered two cardiac arrests, with his death verified on 15 November 2022. Concerns included delays in blood tests, CT scanning, escalation to the Intensive Care Unit and prescribing antibiotics, as well as overcrowding, inadequate escalation arrangements and training needs concerning atypical sepsis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in completion of night-time blood tests
Wider context from the report
“a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective night-time Internal Escalation Policy measures
Wider context from the report
“d. The lack of a specific night time Internal Escalation Policy. A number of the general Internal Escalation Policy measures are not effective at night; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in notification of abnormal blood test results to clinicians
Wider context from the report
“a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
Wider context from the report
“f. The need for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of contemporaneous record keeping in the Emergency Department
Wider context from the report
“c. The lack of contemporaneous record keeping in the Emergency Department; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call
Wider context from the report
“e. The need for training of all Intensive Care Unit clinicians at all levels, both existing Intensive Care Unit clinicians and new joiners, in the policy that a "just to let you know" call should result in an Intensive Care review of the patient; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Burdensome and time-consuming out-of-hours CT scan requesting system
Wider context from the report
“b. The burdensome and time consuming out of hours system for clinicians requesting CT scans from an external provider; ”
Open source report
28 Nov2018
Berkshire
Concerns raised6
1. Lack of knowledge of the signs and symptoms of venous thromboembolism
2. Insufficient medical registrar cover at night
3. Deficient GP record-keeping practices
1. Insufficient clinical knowledge of unexpected deaths and related clinical management
2. Failure of the GP practice system to investigate unexpected deaths
3. Deficient GP record keeping
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Michelle Roach · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of knowledge of the signs and symptoms of venous thromboembolism
Wider context from the report
“(1) I believe ████████ should consider reviewing and updating her knowledge in relation to the signs and symptoms of venous thromboembolism. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient medical registrar cover at night
Wider context from the report
“(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Deficient GP record-keeping practices
Wider context from the report
“(2) I believe ████████ should review her record-keeping practices. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient clinical knowledge of unexpected deaths and related clinical management
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the GP practice system to investigate unexpected deaths
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Deficient GP record keeping
Wider context from the report
“(3) The GP practice should review their system for investigating unexpected deaths in order to learn from them and improve clinical management. It should also audit and review ████████ clinical knowledge in this area and her record keeping. ”
Open source report
3 Aug2015
Berkshire
Concerns raised1
1. Failure to maintain an evidence-aligned policy for perioperative blood glucose levels
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr Michael Quinn · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Michael Quinn underwent lumbar decompression surgery and was discharged home, but subsequently developed diarrhoea and vomiting, was admitted critically ill, and died despite intensive treatment. The principal concern was confusion and inconsistency about appropriate perioperative blood glucose levels for patients undergoing surgery, including a written policy that did not align with national guidelines and other published research.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain an evidence-aligned policy for perioperative blood glucose levels
Wider context from the report
“(2) It is clear to me that there is a great deal of confusion about what is an appropriate level for patients such as Mr Quinn and the optimal blood glucose level that should be achieved in patients, diabetic or otherwise, prior to surgery. While I did not find at the Inquest that Mr Quinn’s blood glucose level of 13mmol was a factor in the infection that led to his death, I am nevertheless concerned that the written policy in place at the time does not mirror that of the national guidelines and is also at odds with other published research articles. (3) I am directing this report to you because I understand that the method adopted by Circle Hospital was based on the policy of your Trust which took the lead in these matters. ”
Open source report
5 Jan2015
Berkshire
Concerns raised2
1. Failure to highlight the cot-side locking problem in all trolley maintenance schedules
2. Failure to escalate and notify trolley users of the known cot-side locking risk
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

James Wilson Fyfe · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James Wilson Fyfe died on 21 April 2011 from pneumonia significantly contributed to by a cervical spine fracture sustained when he fell from a hospital trolley after its cot side gave way. Concerns related to the trolley remaining raised but unlocked due to design, maintenance and use issues, and to uncertainty about whether the known hazard had been communicated to other users of the trolley.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to highlight the cot-side locking problem in all trolley maintenance schedules
Wider context from the report
“(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. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate and notify trolley users of the known cot-side locking risk
Wider context from the report
“(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. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure of obstetricians to undergo incident-derived training

Concerns raised7

Delays in completion of night-time blood tests

Lack of effective night-time Internal Escalation Policy measures

Delays in notification of abnormal blood test results to clinicians

Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate

Lack of contemporaneous record keeping in the Emergency Department

Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call

Burdensome and time-consuming out-of-hours CT scan requesting system

Concerns raised6

Lack of knowledge of the signs and symptoms of venous thromboembolism

Insufficient medical registrar cover at night

Deficient GP record-keeping practices

Insufficient clinical knowledge of unexpected deaths and related clinical management

Failure of the GP practice system to investigate unexpected deaths

Deficient GP record keeping

Concerns raised1

Failure to maintain an evidence-aligned policy for perioperative blood glucose levels

Concerns raised2

Failure to highlight the cot-side locking problem in all trolley maintenance schedules

Failure to escalate and notify trolley users of the known cot-side locking risk