White Horse Medical Practice

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First report 23 Sep 2025•Latest report 23 Sep 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
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from White Horse Medical Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Wiltshire and Swindon

    AI-generated summary

    Christopher John Bird (“Chris”) · 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

    Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.

    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 White Horse Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Systemic failure in communication between mental health and primary care

    Wider context from the report

    “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024. If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost; During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again. It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter. ”
    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 White Horse Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of nhs.net email to reliably deliver important information to GP practices

    Wider context from the report

    “During the course of the Inquest, I heard evidence from ████████ the joint Senior Partner at The White Horse Medical Practice. Having asked colleagues to carry out a forensic search for evidence of the e-mail having been received and finding none he did allude to a view that was not shared by him alone, but by colleagues both within the Surgery and it appears colleagues in other surgeries that there were concerns that when using the nhs.net e-mail e-mails had gone missing and were not received through the system suggesting its 100% reliability. I personally have not come across another case where this issue has been raised but there is no evidence that I saw that pointed to the e-mail having been incorrectly sent by mental health to the GP practice and I have to accept ████████ evidence that there is no evidence to support it was in fact received. The systemic failure in my view more than minimally contributed to the deterioration in Chris’ mental health that led to his death late afternoon on the 19 September 2024. When Chris spoke with another GP on the 16 September 2024, she was unaware of the response from mental health because the e-mail indicating in detail the nature of that response was never received by the GP practice. She in turn contacted the embedded mental health social worker the next day via e-mail although however he was not available that day hence the assumption that that was the reason if not a combined reason for Chris’ case being discussed at the hub meeting on the 19 September 2024. If there is a reliability issue with the use of nhs.net for whatever reason such as old infrastructure, in that clearly is a concern and one which I am of the view could impact on future deaths if important information having been sent through the system is not guaranteed to be received and is lost; During the course of the Inquest it became clear that there had been a systemic failure in relation to the communication from mental health to primary care on the 28 August 2024 and I asked and indicated that I would like both organisations to work together to reflect on the finding in relation to ways of working relative to the interaction between secondary and primary care levels to see if there are any measures that could be undertaken to minimise and ideally exclude the repetition of such an incident occurring again. It is not the job of a Coroner to make recommendations. You are aware of my concern here and I am sure that Chris' brother, ████████ would equally welcome your joint input in respect of the matter. ”
    Open source report
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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