Lives are being put at risk and the situation needs to be addressed urgently. This was the conclusion drawn by Senior Coroner for the Milton Keynes area, Tom Osbourne, during the recent inquest into the death of Mr John Shrosbree who died at the hospital just days after being admitted.

During an inquest the Coroner will simply seek to answer the questions of who the deceased was, where, when and how they died.

The Coroner will either reach a one-line verdict such as death by “natural causes” or in certain circumstances, a narrative verdict will be more appropriate which gives a more descriptive explanation as to the events surrounding the death.

The Coroner also has the power to make a Regulation 28 Report otherwise known as a Prevention of Future Deaths Report, which will be particularly appropriate when systemic failures appear to have played a part in the events leading up to the death. This report requires the relevant party or organisation to produce a response addressing the Coroner’s concerns and considering ways in which improvements might be made.

The facts

Mr Shrosbree, age 72, was admitted to the Milton Keynes University Hospital via ambulance on 4 June 2019. Tests on his admission showed that he was suffering with high potassium levels and he was unwell. Unfortunately, he was not frequently monitored, nor were his results reviewed or his care expedited quickly enough and there were extensive delays in starting treatment to reverse his condition. Whilst at the hospital Mr Shrosbree suffered a Cardiac Arrest as result of his deteriorating state, this then led to oxygen deprivation and brain damage. Tragically, Mr Shrosbree died at the Hospital on 11 June 2019.

At the inquest, the Coroner returned a narrative conclusion and raised the following concerns in a Regulation 28 Report to the Milton Keynes University Hospital NHS Foundation Trust.

“My concern is that during the evidence it became clear that the problems encountered at the emergency department on 4 June 2019 were mainly brought about by staff shortages. I was told that staff shortages occur on a daily basis and I believe that as a result of this the citizens of Milton Keynes are being put at risk and the problem should be addressed as a matter of urgency”

The hospital must respond to this within 56 days, by the 21 November 2019. The BBC reports a representative for the Hospital said it accepted the Coroner's findings and had increased the levels of nursing leadership in the emergency department.


This action by the Coroner should be welcomed. Hospitals that allow departments to operate without the requisite number of staff to provide a good standard of care must be held accountable if we are to prevent tragic cases such as this: They are placing an unfair pressure on staff that are available to work and are gambling with patient safety. The question is how many more patients have received poor treatment at this hospital whilst staff shortages have been allowed to persist: This inquest is most likely to be the tip of the iceberg.

If you are concerned about the care which you or a loved one has received or you require legal representation at an inquest, please contact a member of our specialist clinical negligence team in Milton Keynes on 01908 668 555 for a free, confidential discussion.

The Freeths national clinical negligence team is headed by:

Carolyn Lowe, Partner (Oxford/Milton Keynes/London) - 01865 781019 /

Karen Reynolds, Partner (Derby/Stoke on Trent/Birmingham) - 0845 274 6830 /

Jane Williams, Partner (Leicester/Nottingham) - 0845 272 5724 /