Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0477, written 23 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Sep 2025 |
|---|---|
| Reference | 2025-0477 |
| Deceased | Christopher Bird |
| Coroner | David Ridley |
| Coroner area | Wiltshire and Swindon |
| Category | Suicide (from 2015) · Railway related deaths |
| Organisation named | Oxford Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HM Senior Coroner for Wiltshire and Swindon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) NHS England PO Box 16738 Redditch B97 9PT (2a) Trust Solicitor and Risk Manager Oxford Health NHS Foundation Trust Littlemore Mental Health Centre Oxford 0X4 4XN (2b) Joint Senior Partner White Horse Medical Practice Faringdon SN7 7YU CORONER 1 2 I am David Ridley, Senior Coroner for Wiltshire and Swindon CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.qov.uk/ukpqa/2009/25/schedule/5/paraqraph/7 http://www.leqislation.qov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 1 October 2024, I opened an Inquest into the death of Christopher John Bird (“Chris"). Chris died tragically when he placed his head on a railway line near South Marston adjacent to the A420 in Swindon late afternoon on the 19 September 2024 in front of an approaching freight train. His death was instantaneous when he was struck by the freight train. Chris was 49 years old when he died. I concluded Chris’ Inquest on the 17 September 2025. I found the medical cause of death was as follows:- la. Traumatic Head Injury lb. Impact from a Train 2. Anxiety and Depression I additionally recorded that Chris’ death was suicide, as a short form conclusion. In response to the question as regards when, where and how (by what means and circumstances Chris came by his death) I recorded in box 3 on the Record of Inquest as follows: - Christopher died from a traumatic head injury when he was struck by a scheduled freight train service as it was travelling on the main railway line near South Marston adjacent to the A420 at approximately 1745 on 19 September 2024.Christopher had chronic mental health issues (mixed anxiety and depression) which were more likely than not were exacerbated as a result of him not being updated by primary care prior to his death as regards the progress of a recent GP referral seeking mental health input. A response from mental health was sent but was not received by the GP practice on 28 August 2024. Wiltshire & Swindon Coroner’s Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP CIRCUMSTANCES OF THE DEATH Expanding on what 1 recorded as regards the when, where and how Chris came by his death, Chris had a history of depression dating back to around 2008. In 2024 his condition began to deteriorate, and he had been off work for a considerable period of time in the lead up to his death. Chris had been diagnosed earlier in the year with low testosterone levels, and 1 heard evidence from those supporting him in that respect that low testosterone can induce low mood and 1 found as a fact that his low testosterone levels were probably one of the factors in relation to his deteriorating mental health and in particular increased anxiety and depression. His brother Tim Bird did in his statement describe Chris as somebody who would overthink problems and during the course of the Inquest although not strictly given as evidence, he did have concerns that potentially his brother may have had autism, but this was never formerly pursued as a diagnosis. Chris sought help from his GP on 27 August 2024, in which he reported that he had been suffering and struggling with severe anxiety recently and was not in a good way. Chris mentioned some suicidal thoughts and the discussion with the GP discussed Chris’ desire to recommence a drug called Quetiapine, a mood stabiliser. Chris mentioned that he had taken the drug previously and recalled that he felt it helped with his symptoms. The GP promptly made a referral to the mental health teams, as Quetiapine needed to be authorised by a psychiatrist, and also whether or not Chris needed special mental health input. The referral was received by the mental health team the following day on the 28 August 2024 and a response was sent back using the nhs.net e-mail system the same day in which it was confirmed that a psychiatrist had approved recommencing Quetiapine and additionally confirming that mental health was comfortable with Chris’ condition being managed at primary care level. There was no evidence that pointed to this e-mail not having been sent by mental health and the e-mail including address was copied into mental health records was confirmed as being accurate. That having been said there was no evidence that the e-mail was received by the White Horse Medical Practice even having forensically examined their records. Those on the front line were unaware of the response from Mental Health until Chris’ case was discussed during a mental health hub meeting during lunchtime on the 19 September 2024. It was not clear as to what triggered Chris’ case to be discussed and it could have been either or a combination of an e-mail sent by another GP in the practice following a conversation with Chris on the 16 September 2024 to the embedded mental health social worker in the practice or another branch of mental health to do with talking therapies which had made contact with the GP Surgery to do with the mental health referral on the 18 September 2024. Before the embedded mental health social worker could try and contact Chris he had tragically died. I found as a fact that Chris’ mental health issues and in particular his mixed anxiety and depression were more likely than not exacerbated as a result of him not being updated by primary care prior to his death as regards the status of the recent mental health referral but that having been said my findings also reflected that the response sent by mental health was not received by the GP practice on the 28 August 2024 and therefore primary care was unaware of the response and the direction from mental health. 5 CORONER’S CONCERNS a. NHS England 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 that e-mails had gone missing and were not received through the system questioning 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 here 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 Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP 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, then 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; b. Oxford Mental Health Services and White Horse Surgery 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 November 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, (brother) , Secretary of State for Health and Social Care, and I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9. Dated 23 September 2025 Signature ____________ ________ David Ridley, Senior Coroner for Wiltshire & Swindon _ _ Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr David Ridley
HM Senior Coroner
Wiltshire and Swindon Coroner’s Service
26 Endless Street
Salisbury
Wiltshire
SP1 1DP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
20th November 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Christopher John Bird
who died on 19 September 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23
September 2025 concerning the death of Christopher John Bird (“Chris”) on 19
September 2024. In advance of responding to the specific concerns raised in your
Report, I would like to express my deep condolences to Chris's family and loved ones.
NHS England is keen to assure the family and yourself that the concerns raised about
Chris’s care have been listened to and reflected upon.
Your Report raised concerns with the reliability of the NHS.net email system.
Specifically, an email sent from the mental health team on 28 August 2024, to confirm
the psychiatrist’s approval of Chris recommencing the drug Quetiapine, appeared not
to have been received by the GP surgery. The inquest heard that a forensic search for
the email had been undertaken by the GP surgery, but it could not be found. The GP
surgery and other unnamed surgeries were concerned that emails sent using the
NHS.net system had gone missing and were not received, questioning its 100%
reliability.
NHSmail
The whole of the NHS in England uses NHSmail, now called ‘NHS Connect’, which is
a cloud-based secure encrypted Microsoft 365 email and office platform, utilising
Microsoft's latest technology within an agreed Health Memorandum of Understanding
(MOU). The technology and security supporting it has various mechanisms in place to
address email audit and tracking when required.
NHSmail is used for clinical communications particularly between NHS organisations
and best practice advice for its use is available on NHS England’s website. This best
practice guidance advises that NHSmail practice inboxes (including generic or shared
inboxes, which most GP practices have) should not be used for urgent clinical advice.
Your Report does not specify whether the mental health referral in Chris’s case was
routine or urgent, however our investigations indicate that the referral was classified
as routine, as detailed further below.
NHSmail is considered a reliable and resilient email platform, specifically designed
and maintained for NHS business communications, with systems put in place to
protect and recover from common IT failures like outages. While occasional incidents
do occur, such as delayed arrival of emails in the destination mailbox, the overall
reliability is strong, and service status is closely monitored and reported on the NHS
support webpage, with disruptions usually resolved quickly and service continuity
prioritized. All users of NHSmail are encouraged to contact their local administrator or
service desk if they are experiencing any issues. If these cannot be resolved by the
user’s local IT team, then there is a national NHSmail helpdesk which operates 24
hours a day.
Prior to the roll out of NHSmail across England, Clinical Safety Cases, Hazard Logs,
and Data Protection Impact Assessments were undertaken to support the delivery of
the service at a national level. Clinical Safety Cases are used to ensure any clinical
risks, hazards and potential harms are identified prior to deployment and these are
managed within either product development or within system adoption methodologies.
The model uses joint data controllers and clearly sets out in the requirements of
organisations using the service, that they have similar local-level policies in place.
Audit Trail and Tracking
NHSmail provides several
for
administrators and users to track actions in the NHSmail portal, such as account
management, mailbox access, and system changes.
layers of audit
the ability
including
logging,
For message-level audit, NHSmail supports requesting read and delivery receipts in
both Outlook and through the NHSmail web interface, allowing users to verify if an
email has been delivered and/or opened by recipients. This is not an automatic
process, and users must select whether they require a delivery and/or read receipt
before sending an email.
NHSmail encrypted emails have a tracking log, showing when a recipient has
accessed a message, supporting clinical and information governance compliance for
sensitive communications.
Emails sent and received are retained on the NHSmail Connect platform for at least 2
years, making them available for forensic discovery and retrospective audit if needed.
These logs and metadata support robust investigations in the case of disputes or
concerns about message transmission, delivery, or security events.
Further investigations into this specific matter
Forensic discovery searches are not something that can be done by individuals within
a GP practice or their Integrated Care Board (ICB), and NHS England has a standard
policy on how forensic searches must be undertaken.
All forensic search requests need to be made via the Helpdesk self-service request
process, as published in the NHSmail Forensic Discovery guide.
All forensic search requests for emails or any other data within the NHSmail service
are recorded for audit purposes.
NHS England can confirm that no forensic search request was made by the White
Horse Medical Practice or their ICB in relation to this case. Therefore, any internal
searches conducted by the practice would not have returned the results relating to any
emails that had been deleted, whether intentionally or in error.
In light of your Report, NHS England has conducted a full forensic discovery search,
the results of which are outlined below.
Search Results
Forensic discovery has confirmed that a referral letter was sent from the White Horse
Medical Practice via the electronic referral service (e-RS) to the community mental
health team at 8:40am on 28 August 2024 by the GP administration team.
A
(
response email was
then sent
from
the
local mental health service
), with the subject line
”, which was received by the practice
on 28 August 2024 at 11:19am. The email was received into the
email account. This is a shared mailbox which is
accessible by 16 members of staff at the White Horse Medical Practice.
The email confirms referral to the Consultant Psychiatrist and that Quetiapine was
recommended, to be recommenced as per the British National Formulary (BNF)
guidelines as it was previously well tolerated by the patient.
In accordance with the NHSmail Clinical Safety Case, the NHSmail service is not
intended for the long-term storage of clinical/patient data. Any valuable information
contained in an email should be copied and recorded in the appropriate patient record.
The forensic search has also confirmed that the full text of the email from the mental
health team had been copied into the patient summary and was available via the
practice’s clinical system (EMIS). This indicates that the GP practice received the
original email and attached the full email text into Chris’s summary notes, making them
available to staff in the practice.
Having copied the contents of the email into the patient record, the original email then
appears
to have been deleted
shared mailbox
from
the
and in line with the NHSmail guidance.
This was good practice by the GP administrators
As NHS England only retains an audit log detail for 180 days, it is not possible to
confirm who deleted the email or exactly when. However, we have been able to
recover the original email from the recoverable-items folder of the shared mailbox, a
folder only visible to those undertaking the forensic discovery process.
Emails that are deleted by a user are moved to the recoverable-items folder for the
purposes of retention and discovery. Had a forensic search request been made nearer
the time (i.e. late 2024 or early 2025), the additional audit data would have been
available. This information may be useful to the practice in the future if they believe
any documentation to have gone missing or to not have been received.
Additionally, in this case we can see that there were two recorded attempts by the
practice to contact Chris by telephone on 6 September 2024 and two online
consultation requests by Chris on 13 and 16 September 2024.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Chris,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
Private & Confidential Mr David Ridley HM Senior Coroner for Swindon and Wiltshire 13 November 2025 Dear Mr Ridley, Inquest into the death of Christopher Bird Thank you for your letter dated 23 September 2025 and your report to prevent future deaths. Your concern is rooted in the means of communication on 28th August 2024 from the Trust to the GP, White Horse Medical Centre. That communication was an email that followed a referral from the GP to the Trust. The email was sent from an Oxford Health email to an nhs.net email. The email contained medication advice from a Trust consultant. The GP gave evidence that the practice does not have any evidence that the email was safely received. You accepted that evidence and you explored the impact that this had on Chris. Your judgement was that Chris’s mental state deteriorated over the three weeks between 28 August 2024 and his death, contributed to by Chris’s frustration that he did not know what was happening in relation to his referral to mental health services. You heard from Chris’s GP that they spoke to Chris on 17 September 2024, and that the GP did not have sight of the 28 August 2024 email when they spoke to Chris. You heard evidence that three Trust services had contact with Chris – (1) Oxfordshire Talking Therapies (2) the Didcot, Wantage and Faringdon Primary Mental Health Hub and (3) the South Oxfordshire Adult Mental Health Team. You heard evidence in person from a Primary Care Mental Health Worker, who is a member of the Trust’s Hub service and who is based at the White Horse Medical Practice. Each of the services has reflected on your concern – 1. Oxfordshire Talking Therapies The Oxfordshire talking therapies service was commissioned by the CCG/general practitioners for Oxfordshire, with an established practice by which the service communicates with GPs. This is a system called DocMan. That system has been the agreed process for many years and the Trust’s position is that it provides effective, timely and secure communication between Oxfordshire Talking Therapies and GPs. 2. Primary Care Mental Health Hubs The manager of the Didcot, Wantage and Faringdon Hub (“DWF Hub”) attended the inquest and provided you with some evidence on the day. They have introduced an immediate change to the practice at the DWF Hub. The change is that the DWF Hub has changed its practice, and now also uses the DocMan system as the means of communication with GPs with regard to the outcome of a referral. The team no longer uses email, save where there is an explicit request for email to be used by the referrer. DocMan works through the electronic health records system called RiO, which is the electronic health records system used by the Hub. A letter is created on RiO and, on completion, is saved to RiO and at the same time sent by automated process to the GP’s system. The DWF Hub manager reports that the change has been very well- received by members of their team. There are seven other Hub teams in Oxfordshire (eight in total with the DWF Hub being one). The plan is for the Trust to evaluate the use of DocMan by the DWF Hub and we will then utilise Trust governance processes to make a decision on whether the new process is adopted in each of the hubs. 3. Adult Mental Health Teams (AMHTs) I have been informed that the Trust’s Associate Director of Adult & Older Adult Mental Health and Partnerships spoke to Service Manager colleagues on 2nd October 2025 about Chris’s case and the issue with email and use of DocMan. Service Managers identified some issues and concerns and were not at that stage in a position to say that the AMHTs will move across to using DocMan in AMHTs and Older Adult services. Service Managers agreed to talk to their teams about how communication with GPs is happening and whether anything can/should be done to make an 2 improvement. Email communication with GPs is commonplace across AMHTs and the Trust must apply diligence to any decision to direct staff to change their practice. That is particularly so because managers are not aware of any similar incidents between AMHTs and GPs and the Trust is reticent to make what could be a significant change without being confident that it will have utility for service users of AMHT services. The Trust has decided that we will complete a review to identify what changes to current practice are available as options and which of those options may add to the controls in place to prevent the risk of a GP not receiving an important communication from the AMHT in a timely way. We will not implement any changes without a clear understanding of the potential consequences. We will also consider a wider consultation with GP representatives and the Integrated Care Board in order to gain a broader understanding of the perspective of GPs. The Trust’s participation in Chris’s inquest has been invaluable for the Trust to understand the learning points and opportunities to make improvement in the communication between services. I can assure you that all staff and managers involved have reflected at some length on the findings of the inquest and we are striving to makes changes with real utility for our staff and those that use OHFT’s services. Yours sincerely, Chief Executive Officer Oxford Health NHS Foundation Trust 3
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