Avon and Wiltshire Mental Health Partnership NHS Trust

31 Prevention of Future Deaths reports name this organisation, 2013–2025. Every report below links to the original on judiciary.uk.

Reports per year

20131
20141
20156
20166
20173
20183
20196
2020
20212
20221
2023
2024
20252

Responses published

22 of 31 reports (71%) have at least one response published on judiciary.uk.

For reports written in the same years, 70% of all PFD reports in the corpus have a published response — so this page is in line with the corpus rate — the difference is within what chance alone would produce for this few reports.

This is not a reply rate. It counts responses published against the report by anyone — the organisation named here, a government department, a regulator or another body — because most response letters do not identify their author in a form that can be resolved reliably. A report with no response listed does not mean nobody replied: publication is at the discretion of the Chief Coroner's office, is often delayed, and was far less consistent in the corpus's early years. Treat a low figure as a prompt to read the reports, not as a finding about this organisation.

Coroner categories

Hospital Death (Clinical Procedures and medical management) related deaths 6Mental Health related deaths 4Suicide (from 2015) 2Mental Health related deaths; Suicide (from 2015) 2Alcohol, drug and medication related deaths 2Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths 1Community health care and emergency services related deaths; Suicide (from 2015) 1Community health care and emergency services related deaths 1Suicide (from 2015); Mental Health related deaths 1State Custody related deaths 1Community health care and emergency services related deaths; Hospital Death (Clinical Procedures and medical management) related deaths; Suicide (from 2015) 1Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths 1

Coroners who wrote them

All reports

DateDeceasedCategoryCoronerResponse
19 Nov 2025Anna BurnsAlcohol drugs and medication related deathsGrant Daviesnone publishedsource
21 Jul 2025Christopher O’DonnellAlcohol, drug and medication related deathsIan SingletonHome Group Limitedsource
2022Ami MitchellSuicide (from 2015)Simon FoxAvon and Wiltshire Mental Health Partnershipsource
8 Jul 2021Maria Stancliffe-CookMental Health related deaths | Hospital Death (Clinical Procedures and medical management) related deaths | Suicide (from 2015)Maria VoisinAvon and Wiltshire Mental Health Partnership NHS Trust, DHSCsource
29 Jun 2021Katie LockeHospital Death (Clinical Procedures and medical management) related deaths | Other related deaths | Police related deaths | Mental Health related deathsAlison McCormicknone publishedsource
28 Nov 2019Thomas WedrychowskiHospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deathsNicholas Rheinbergnone publishedsource
19 Nov 2019Shaun DeweySuicide (from 2015); State Custody related deathsMaria VoisinDirector General of Prisons Redacted 1source
10 Oct 2019Abdeslam BenelghaziAlcohol, drug and medication related deaths; Mental Health related deathsMaria VoisinDepartment of Health and Social Caresource
28 Jun 2019Heather BirchallAlcohol, drug and medication related deathsDavid Ridleynone publishedsource
16 May 2019Natasha AbrahartMental Health related deaths; Suicide (from 2015)M.E. VoisinUniversity of Bristol, AWP, the Department for Health and Social Caresource
10 Jan 2019Christopher SealCommunity health care related deaths; Mental Health related deathsMaria VoisinAvon and Wiltshire Mental Health NHS Trustsource
14 Sep 2018Terence BennettMental Health related deaths; Suicide (from 2015)Nicholas RheinbergNHS Improvementsource
21 May 2018Michalla SweetingCommunity health care and emergency services related deaths; State Custody related deathsMaria Voisinnone publishedsource
3 May 2018Martin BakerHospital Death (Clinical Procedures and medical management) related deathsAndrew CoxBath North East Somerset NHS Trustsource
13 Dec 2017Rebecca RomeroChild Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deathsMaria Voisinnone publishedsource
7 Jun 2017Callum SmithCommunity health care and emergency services related deaths; Hospital Death (Clinical Procedures and medical management) related deaths; Suicide (from 2015)Maria VoisinPrison Health Servicessource
9 Feb 2017Matthew RobertsHospital Death (Clinical Procedures and medical management) related deathsBridget Dolan QCSussex Partnership NHS Trustsource
14 Nov 2016Martyn WatkinsSuicide (from 2015); Mental Health related deathsDr Peter HarrowingCare Quality Commissionsource
12 Oct 2016Calam AtourState Custody related deathsDavid Ridleynone publishedsource
5 Sep 2016John JonesMental Health related deathsRobert Sowersbynone publishedsource
15 Aug 2016Oliver FordMental Health related deathsMaria VoisinAvon and Wiltshire NHS Trustsource
7 Aug 2016Rohan FitzsimonsCommunity health care and emergency services related deathsPeter HarrowingAvon and Wiltshire NHS Trustsource
29 Jul 2016Miles AbelCommunity health care and emergency services related deaths; Suicide (from 2015)Ian SingletonDepartment of Health, The Endless Street Doctors Surgerysource
27 Oct 2015Charlotte Bevan and Zaani MalbrouckChild Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deathsMaria VoisinRespondent not namedsource
24 Jul 2015Simon ReynoldsMental Health related deathsMaria Voisinnone publishedsource
17 Jul 2015Masoud GhaderiHospital Death (Clinical Procedures and medical management) related deathsPeter HarrowingAvon and Wiltshire NHS Trustsource
19 Jun 2015Elizabeth GodwinHospital Death (Clinical Procedures and medical management) related deathsIan SingletonWiltshire Council, Royal United Hospitals Bath NHS Trust, Avon and Wiltshire NHS Trustsource
20 Apr 2015Andrew FarrowHospital Death (Clinical Procedures and medical management) related deathsPeter HatvanyAvon and Wiltshire NHS Trustsource
4 Mar 2015Kimberley ParsonsSuicide (from 2015)P HarrowingCare Quality Commission, Avon Wiltshire NHS Trustsource
8 Apr 2014Andrew HorganHospital Death (Clinical Procedures and medical management) related deathsDavid RidleyGreat Western Hospital NHS Foundation Trustsource
12 Dec 2013Felix CembrowiczMental Health related deathsTerence MooreAvon Wiltshire NHSsource

These counts are a floor, not a total. A report is listed here only when it names the organisation in text our pipeline could read; scanned reports with poor OCR, and reports that name only a hospital site or an individual, are missed. Always check the source report.

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