Coroner calls for action on poor record-keeping at Wexham Park after man's death

A coroner has said action should be taken by the trust running Wexham Park Hospital to address poor record-keeping identified at an inquest into a man's death.

Patrick Coffey, 85, died at the Slough hospital while he was being treated for multiple rib fractures and a chest infection in September last year.  

Gaps amounting to more than a day in Mr Coffey’s records meant he had ‘probably not’ received proper treatment, coroner Robert Simpson said in a prevention of future deaths report.

A spokesperson for NHS Frimley Health Foundation Trust – which runs Wexham Park - said its records ‘should have been better’ and a review was underway into its notes system.

Mr Coffey fell over at his home and suffered multiple rib fractures on September 12, 2024. He was on the floor for 17 hours before being taken to Wexham Park Hospital.  

Medics there found that Mr Coffey, who lived with the breathing condition chronic obstructive pulmonary disease [COPD], was also suffering from a chest infection.

His condition should have been treated with pain control medication and regular adjustments to his posture, being moved from lying to sitting every two to four hours.

Patients with chest infections, and particularly with chest injuries, need repositioning to help with their breathing and coughing.

But in his prevention of future deaths report, coroner Robert Simpson found ‘this was not always offered or achieved’.

An inquest into Mr Coffey's death concluded on June 6, 2025 (pictured: Reading Coroner's Court)

Up to 27 hours of missing entries in Mr Coffey’s patient notes ‘do not show repositioning every two to four hours’, Mr Simpson said in the report.

“These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a two to four hourly basis,” he added.

“The medical records from the hospital do not show repositioning every two to four hours and I found that Mr Coffey was probably not repositioned as required.”

Mr Simpson’s report said that, while the problems ‘did not contribute’ to Mr Coffey’s death, there was a risk to the lives of future patients at Wexham Park Hospital.

Mr Simpson said: “[The] lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage.”

The hospital itself had identified the problem during monthly audits where it found ‘this was either [not] being done or not being properly recorded for some patients’, the report said.

NHS Frimley Health trust must respond to Mr Simpson’s report and include actions being taken as a result of it.

A trust spokesperson said: “Although the coroner found that Mr Coffey’s care at Wexham Park Hospital did not contribute to his death, we acknowledge that our records relating to his repositioning should have been better.

“The repositioning of patients remains an important area of staff training, and we are reviewing our electronic patient record system to ensure that repositioning is always fully documented.

“We will be sharing full details with the coroner.”