Hospital criticised for ‘poor’ and ‘defensive’ investigations

A hospital trust has been criticised for its “poor” and “defensive” investigations into three deaths, which a coroner has linked to care by a single surgeon. 

Heidi Connor, senior coroner for Berkshire, investigated three deaths that occurred within three months at Royal Berkshire Foundation Trust. Each death followed surgery by consultant colorectal surgeon Daniel McGrath, whose “management” of each case was criticised by experts cited by the coroner. 

The coroner’s prevention of future deaths report about the death of Lorraine Parker, who died most recently of the three on 30 March 2024, was published last week and examined the trust’s death investigations processes across each of the three cases.

Ms Connor found the trust’s structured judgement reviews - which investigate care failings following a patient death - to be “at best, poor” and “at worst, defensive”, and warned the trust that its overall death investigation process “is not working well”. 

In addition, the coroner questioned “whether the trust has done enough to deal with the concerns about this particular surgeon” following the three deaths. 

There is no note of a restriction on Mr McGrath’s practice according to the General Medical Council register. However, Royal Berkshire told HSJ it has “worked closely with the coroner and the GMC” on measures to oversee his work. He has also been removed from surgical duties.

Looking at how the trust handled investigations into the three deaths, the coroner’s report noted the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report”, which supports responses to patient safety incidents, into any of the deaths. 

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Source: HSJ, 1 May 2025