Slough inquest: No missed opportunities in rail deaths

Slough train station
Image caption Rubina and Amaar Khan were killed when they were hit by a train at Slough station

A coroner has said there were "no missed opportunities" in the care of a mother who jumped in front of a train with her 10-year-old son.

Rubina Khan and Amaar Khan died when they were hit by a train at Slough railway station on 23 September 2014.

Their family accused health services of "shortfalls" in her treatment, with concerns "not taken seriously enough" in the months before her death.

Conclusions of suicide for Mrs Khan and unlawful killing for Amaar were given.

Senior coroner Peter Bedford said there was "no shying away from the fact that a number of significant findings and areas of improvement" were identified to the health services.

However, he said there was "no missed opportunity to predict, act and thereby prevent" the deaths that occurred.

The two-day inquest heard the mother "jumped" with her son on to the tracks before they were struck by a high-speed train.

Mrs Khan, 46, had suffered from depression, which led to her having panic attacks and self-harming on occasions, Reading Coroners' Court heard.

The mother-of-three had been admitted twice in July to Prospect Park Hospital, in Reading, and was seen by an unnamed GP five days before she died.

Image copyright Andrew Abbott
Image caption British Transport Police at the time said there was a possibility the case was a murder-suicide

Ann Owen, an independent management consultant, said a review found gaps in recording and documentation relating to Mrs Khan's care by the trust.

Dr Kesar Singh Sadhra, another GP at Manor Park Medical Centre in Slough, said there would have been a "completely different perspective" on Mrs Khan's care if they had been given more details about self-harming incidents, but added it was "unlikely" to have made a difference.

The family said their concerns were "not listened to and there were breakdowns in communication", the inquest heard.

Berkshire Healthcare NHS Foundation Trust had made improvements and there were now systems in place that "appeared to be lacking in this case", Mr Bedford said.

Consultants said there was no evidence or suggestion that Mrs Khan was a risk to her children or at risk of taking her own life.

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