Lorraine Parker (1)

“On the evidence I have seen from the three inquests referred to, the Royal Berkshire Hospital's death investigation process is not working well.”

“I have seen evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously.”

“There is little (if any) record of areas of concern identified at meetings - whether at morbidity and mortality meetings or clinical governance meetings.”

“There is delayed escalation of concerns.”

“Structured judgement reviews I have reviewed are at best, poor, and at worst, defensive.”

“Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost.”